Simcoe Muskoka District Health Unit
Policy and Procedure Manual

The health unit believes individuals and groups have the right to make their own health choices.

Consent for treatment* will be sought by health unit staff in a way that supports the person throughout the decision making process without unduly influencing the decision. Health Unit staff will be required to apply their professional judgement in each individual situation.

1. The consent must be specific to the proposed treatment.

2. There must be accurate disclosure of specific information which may include:

• nature and purpose of proposed action
• material risks** and benefits
• reasonable alternatives
• impact upon lifestyle
• economic considerations
• consequences of refusal
• who is doing the treatment

3. The person must have the opportunity to ask questions and to understand the answers provided.

4. The person must possess the mental capacity to consent. The test for mental capacity is:

1. the ability to understand the information relevant to the proposed treatment.
2. the ability to appreciate the reasonably foreseeable consequences of consenting to or refusing the treatment, or of making no decision.

In addition, if capacity is established, in the professional's opinion, the person consents on their own behalf, irrespective of age or parental wishes. Documentation must indicate that capacity was determined (how it was determined that the person met the two tests above).

The Act protects health professionals who proceed with treatment as long as they are able to indicate they believed that the person was capable.

5. The person must be informed that they have the right to withdraw consent.

6. Release of information related to treatment must comply with the Confidentiality Policy and Release of Information Policy (MFIPPA).

* Treatment: the act applies to "health practitioners" and means anything that is done for a therapeutic, preventative, palliative, diagnostic, cosmetic or other health-related purpose, and includes a course of treatment or plan of treatment but does not include a prescribed thing.

** Material Risk: a risk having real importance or great consequences. In law, adequacy of disclosure is assessed in the context of the facts of each particular case. It is not necessary to disclose all known risks - "what the average prudent person, a reasonable person in the patient's particular position, would agree to or not agree to if all material and special risks of proceeding were made known". Professional judgement is required since there is no formula outlining a material risk (eg. a risk with a probability less than 1 per cent need not be disclosed).