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Documentation of Capacity and Identification of Substitute Decisionmakers in Ontario


Documenting capacity assessments and identifying substitute decisionmakers (SDMs) in healthcare facilities is ethically required for optimal patient care. Lack of such documentation has the potential to generate confusion and contention among patients, their family members, and members of the healthcare team. An overview of our research at the Ottawa Hospital and issues that influence the consistency of documentation in the Canadian context are presented here, as well as ideas for the mitigation of these issues and ways to encourage better documentation.

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1. Glezer, A, Stern, TA, Mort, EA, Atamian, S, Abrams, JL, Brendel, RW. Documentation of decision-making capacity, informed consent, and health care proxies: A study of surrogate consent. Psychosomatics 2011;52:521–9.

2. Health Care Consent Act (1996), S.O., c.2, Sched. A. Government of Ontario.

3. Hospitals Act, 2007 (Nova Scotia); Health Act, 2002 (Yukon Territory); Health Care (Consent) and Care Facility (Admission) Act (British Columbia), 2000; Health Care Consent Act, 1996 (Ontario); Quebec Civil Code, 1994 (Quebec); Consent to Treatment and Health Care Directives Act 1996 (Prince Edward Island); Medical Consent of Minors Act Mental Capacity (New Brunswick); Health Care Directives and Substitute Health Care Decision Makers Act, 2000 (Saskatchewan); Mental Health Act (Northwest Territories, 1998; Nunavut, 1999); Care Consent Act, 2003 (Yukon).

4. Under these rules, SDMs are obligated to first consider the patient’s previously expressed capable wishes that apply to the circumstances and then consider the patient’s best interests if no such wishes exist. See HCCA, section 21.(1).

5. Ratnapalan, M, Cooper, AB, Scales, DC, Pinto, R. Documentation of best interest by intensivists: A retrospective study in an Ontario critical care unit. BMC Medical Ethics 2010;11:1.

6. Brown, PF, Tulloch, AD, Mackenzie, C, Owen, GS, Szmukler, G, Hotopf, M. Assessments of mental capacity in psychiatry inpatients: A retrospective cohort study. BMC Psychiatry 2013;13:115.

7. See note 1, Glezer et al. 2011.

8. See note 5, Ratnapalan et al. 2010.

9. Winkler, EC, Hiddemann, W, Marckmann, G. Evaluating a patient’s request for life-prolonging treatment: An ethical framework. Journal of Medical Ethics 2012;38:647–51.

10. See note 3.

11. Manitoba Law Reform Commission (2004) Substitute Consent to Health Care, Report #110; available at (last accessed 2 Oct 2013).

13. Etchells, EE, Katz, MR, Shuchman, M, Wong, G, Workman, S, Choudhry, NK, et al. Accuracy of clinical impressions and Mini-Mental State Exam scores for assessing capacity to consent to treatment: Comparison with criterion-standard psychiatric assessments. Psychosomatics 1997;38:239–45.

14. Etchells, EE, Darzins, P, Silberfeld, M, Singer, PA, McKenny, J, Naglie, G, et al. Assessment of patient capacity to consent to treatment. Journal of General Internal Medicine 1999;14(1):2734.

15. Fitten, LJ, Lusky, R, Hamann, C. Assessing treatment decision-making capacity in elderly nursing home residents. Journal of the American Geriatrics Society 1990;38:1097–104.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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