A. INTRODUCTION AND BACKGROUND
During the LCO’s consultations, all stakeholders pointed to shortcomings in understandings of the law and in the skills necessary to apply it as key issues to be addressed in any review. The need for improvements in education and information has therefore been a theme throughout this project, and arises in every Chapter of this Report. This Chapter does not attempt to replicate this material, but to provide a focussed examination of some key elements).
It should be noted that, despite its importance, the provision of information and education is not a panacea for every issue affecting this area of the law. Nor is information the same thing as advice, and on its own does not create the ability to act on it. Nor can education and information themselves create solutions to difficult situations: they can only assist in identifying and accessing what is available.
B. CURRENT ONTARIO LAW AND PRACTICE
1. Understanding Needs for Education and Information
In considering reforms to promote better understanding (and therefore better implementation) of the law, the needs of four groups must be taken into account.
Persons directly affected by the law will be the most profoundly affected by the quality and extent of the information they receive about the law. The information that they receive will substantially shape their ability to make meaningful choices in this context and to protect and enforce their rights. Except for those persons granting powers of attorney who have sophistication in handling affairs or easy access to professional assistance, this is also the group that will likely have the most challenges in receiving adequate information, or even in realizing that they could benefit from information. The conditions affecting their legal capacity will affect their ability to understand and appreciate information about the law itself. Many persons directly affected by the law will require accommodations or supports in receiving or accessing information. As well, they will very often encounter the law at a time of crisis, when it is difficult to seek out and process information.
Persons who act as substitutes or supporters will, for the most part, be family members or friends with no particular expertise in understanding or applying the law. Many will also be acting as caregivers, and in most cases, they will not be paid for their activities. In their roles, they will be often required to navigate extensive processes or intimidating institutions, understand novel medical or financial concepts, develop skills as advocates, and manage difficult family or professional relationships. In the LCO’s consultations, these family members often emphasized the challenges of their roles, and the lack of supports available to them.
The employees of third parties such as banks, trust companies, community agencies or many government departments are unlikely to have specialized expertise in this area. Large organizations, such as financial institutions or hospitals, will generally develop internal expertise, perhaps including policies, protocols or guidelines. Smaller organizations may not have the ability to develop these kinds of internal resources. It is important to emphasize that third parties are, by and large, well-intentioned in their efforts to serve their clients, and that they may be operating in contexts of considerable constraint and difficulty. There may be no simple solutions to the ethical, practical or resource challenges that these institutions or professionals may face in providing services to what may at times be their most vulnerable clients, although opportunities do exist to deepen provider competencies in this area through existing institutions and programs.
Professionals who must apply or provide advice on the law as part of their professional duties have the most significant responsibility for ensuring the effective and appropriate implementation of the law. This group includes the professionals who carry out the different forms of assessment of capacity; lawyers who assist with the preparation of powers of attorney or with resolving disputes arising under the law; and hospital or long-term care home staff who develop internal policies and procedures for addressing these issues.
2. Some Legislative History: The Advocacy Act Requirements
When the current legislative scheme was initially proposed, it contained three statutes: the Substitute Decisions Act, 1992 (SDA), the Consent to Treatment Act, 1992 (the predecessor to the Health Care Consent Act, 1992) and the Advocacy Act.
• The Advocacy Act is described at length in the Discussion Paper, Part Four, Ch III.B.
For the purposes of this discussion, it suffices to note that the Advocacy Act and the accompanying provisions in the SDA and Consent to Treatment Act made extensive provision for rights advice. At key transition points in the lives of persons affected by the law where important rights were at stake, advocates were made responsible for and otherwise interacting with the individual in various ways, including the following:
• notifying the individual of the decision or determination that had been made about her or him;
• explaining the significance of the decision or determination in a way that took into account the special needs of that person;
• explaining the rights that the individual had in that circumstance, such as a right to appeal the decision or determination; and
• in some cases, ascertaining the wishes of the individual (e.g., whether he or she wished to challenge the decision or determination) and to convey those wishes to the appropriate body (e.g., the Public Guardian and Trustee).
Action on these decisions or determinations could not be taken until the advocate had carried out these duties, or had made efforts to do so and had been prevented, for example by contravention of their rights of entry. This role was engaged in the following situations, among others:
• the appointment of a statutory guardian of property following an examination under the Mental Health Act;
• the appointment of the Public Guardian and Trustee (PGT) as a temporary guardian following an investigation into serious adverse effects;
• applications for validation or registration of powers of attorney for personal care;
• applications for court-appointed guardianships;
• court orders for assessment of capacity, including orders for apprehension of the individual to enforce assessments;
• findings of incapacity with respect to treatment made within a psychiatric facility;
• findings of incapacity with respect to “controlled acts” in a non-psychiatric facility;
• applications to the Consent and Capacity Board (CCB) for directions regarding the prior expressed wishes of an individual; and
• applications to the CCB for permission to depart from the prior expressed wishes of an individual.
These requirements were removed in 1996, when the Advocacy Act was repealed and the Consent to Treatment Act, 1992 replaced by the current Health Care Consent Act, 1996 (HCCA). While the current legislation contains some provisions related to the provision of information (as is described below), they are minimal compared to the original legislative requirements.
3. Current Statutory Requirements
Currently, the SDA, Part III of the Mental Health Act (MHA) and the HCCA include the following requirements for information to be provided to affected individuals at a limited number of key transition points.
Assessing Capacity: Because an assessment of capacity can in a number of circumstances have very significant automatic effects on the individual’s status and choices, information about the legal effect of the assessment, the rights of the individual and the options available is crucial.
• The provision of rights advice and rights information in these circumstances was discussed at length in Chapter 5.
MHA examinations of capacity to manage property: those undergoing these examinations have a right to notice of the issuance of a certificate of incapacity, and to timely provision of rights advice by a specialized Rights Adviser. The Rights Adviser will provide information to the patient about the significance of the certificate and the right of appeal.
HCCA assessments of capacity to consent to treatment: a finding of lack of capacity must be communicated to the individual. Outside of psychiatric facilities, the form and content of the notice depends on the guidelines of the health regulatory college.
HCCA evaluations of capacity to consent to admission to long-term care or to personal assistance services: the HCCA does not require provision of information to the affected individual; however, the form for evaluators includes an information sheet that must be provided to the individual and a box to tick that the individual has been informed about the finding and the right to appeal.
SDA Assessments by designated Capacity Assessors: the individual must be provided with information about the purpose, significance and potential effect of the assessment, as well as written notice of the findings of the assessment. Where a statutory guardianship results, the PGT must inform the individual that it has become the guardian and that there is a right to apply for review of the finding.
The significant shortfalls in the rights information regime under the HCCA were discussed at length in Chapter 5, and are the subject of several recommendations for reform. It is also worth noting that even where information is provided to individuals, they may face many barriers to acting on that information without further assistance, whether because of disabilities or impairments, a lack of supports or the constraints of their environments.
Roles and responsibilities of Substitute Decision-makers (SDMs): the SDA currently includes several provisions that promote information about rights and assistance. For example, the SDA requires SDMs appointed either through a power of attorney (POA) or a guardianship, to explain their powers and duties to the affected individual. Section 70 of the SDA requires a proposed guardian in a court application for guardianship to include in the application a signed statement either that the person alleged to be incapable has been informed of the nature of the application and the right to oppose it, or explaining why this was not possible. Sections 32(2) and 66(2) require SDMs under the SDA to explain to the individual the powers and duties of the guardian (although not, notably, any means of rights enforcement for the individual).
It is important to note, however, that these provisions are limited: For example, there is no formal mechanism for ensuring that the duties under sections 32(2) and 66(2) are carried out. Nor does the SDA include formal requirements or supports to inform or educate SDMs, or third parties. Persons appointed under a POA need not even be informed that they have been appointed, and there are no mechanisms for ensuring that attorneys understand their role.
4. Non-statutory Provision of Education and Information
There has been considerable effort by a variety of institutions to provide affected individuals, family members and SDMs, professionals and third parties with the information required for the effective functioning of this area of the law.
Educational institutions: Many of the service providers or professionals charged with advising on, applying or supporting the application of the law must meet certain educational requirements prior to entering their professions. This is true for social workers, health professionals and lawyers, for example. Educational institutions may provide information related to this area of the law, either as mandatory or voluntary course material.
Professional regulatory bodies: Professional regulatory bodies play an important role in providing information and education to their members across a wide range of subject areas. Professional regulatory bodies, such as the health regulatory colleges or the Law Society of Upper Canada, may require practitioners to demonstrate specific knowledge or skills to join the profession, and may provide ongoing education and training opportunities. They may develop policies and guidelines of practice that are binding on their members and may be the subject of complaints where there is non- compliance.
Employing institutions: For professionals working in large institutions, such as hospitals, long-term care homes, Community Care Access Centres, or large social service agencies, their implementation of the law will be significantly shaped by their employer. Institutions may develop internal policies dictating how the law is to be interpreted and applied, create internal training programs or resources, or provide access to information and advice through internal legal or ethics departments.
Government mandated training and education: Government does not legislatively or otherwise mandate training or education except in very limited circumstances. The current statutory regime requires those carrying out the various forms of formal capacity assessments to be members of specified professions, and thereby to have completed the requisite education and met accreditation standards. Capacity Assessors who are designated under the SDA, must also complete certain training and requirements to maintain qualification, as is described in Chapter 5 of this Final Report.
Professional associations: Professional associations may also provide materials or continuing education opportunities. For example, the Canadian Medical Association’s Concerns regarding education, information and understanding of the law were prominent in all focus groups, as well as in most of the written submissions that the LCO received.
Code of Ethics includes provisions related to respecting the right to accept or reject treatment, ascertaining wishes and provision of information to patients. The Ontario Bar Association’s Trusts and Estates Section regularly provides Continuing Professional Development related to powers of attorney, as does the Health Law Section with respect to capacity and consent.
Government bodies: The Consent and Capacity Board (CCB), the Ontario Seniors Secretariat, and the Public Guardian and Trustee (PGT) provide informational materials and conduct presentations aimed both at professionals and institutions, and at families and those directly affected. Both the PGT and the Capacity Assessment Office (CAO) receive thousands of phone calls each year, through which they provide information and referral to appropriate resources.
Advocacy and consumer organizations: Organizations that work with and advocate for persons directly affected may develop education and training for professionals, as part of initiatives aimed at closing the implementation gap and promoting the rights of the individuals that they serve, as well as providing information materials and advice to those directly affected. For example, ARCH Disability Law Centre, the Advocacy Centre for the Elderly and Elder Abuse Ontario regularly engage in public education activities in this area.
Academics and experts: Academics and experts may use their skills to develop tools for “knowledge translation”, aiming to turn complex issues of law and professional practice into practical tools or resources. For example, the National Initiative for the Care of the Elderly (NICE) has as its goals to help close the gap between evidence- based research and actual practice; improve the training of existing practitioners and geriatric educational curricula; interest new students in specializing in geriatric care; and effect positive policy changes for the care of older adults.564
C. AREAS OF CONCERN
Concerns regarding education, information and understanding of the law were prominent in all focus groups, as well as in most of the written submissions that the LCO received. In fact, widespread confusion regarding the law among family members, individuals directly affected and many service providers was evident in the focus group discussions.
It is useful to note that similar concerns were raised in the LCO’s project on Capacity and Legal Representation for the Federal RDSP. The LCO there identified that the provision of information in accessible formats, languages and locations would be crucial to the success of any streamlined process, and recommended that Government of Ontario distribute public legal education to potential users of the recommended streamlined process, in a variety of accessible languages