IX. New Roles for Professionals and Community Agencies

////IX. New Roles for Professionals and Community Agencies
IX. New Roles for Professionals and Community Agencies2017-04-24T16:48:59+00:00

A. INTRODUCTION AND BACKGROUND

nder current Ontario law, where a person does not have the legal capacity to make a particular decision or type of decision, a substitute decision- maker (SDM) must be identified. In the vast majority of cases, that SDM will be a member of the individual’s family or a close friend. There are a

relatively small number of individuals who have as their SDMs a professional (such as a lawyer, for example), an organization (such as a trust company) or the government (through the Public Guardian and Trustee (PGT).

The Discussion Paper, Part Three, Ch II, raised the question of whether, in light of changing economics, family structures and demographics, Ontario ought to expand the range of options for appointments as SDMs available to individuals. This Chapter examines that issue.

It should be emphasized that this discussion does not include supported decision- making arrangements, in which the individual makes the final decision with assistance from others. It is the view of the LCO that supported decision-making requires close, trusting personal relationships. While many persons granted powers of attorney (POAs) or appointed as guardians are in trusting relationships with the individual for whom they make decisions and may be selected for such reasons (as discussed below), this is not necessarily the case. Furthermore, where no such relationships exist or they are not appropriate as a basis for decision-making, the more formal accountability mechanisms associated with substitute decision-making are essential.

However, it is worth considering whether expanded roles for professionals and community agencies may include roles as monitors under a POA or supported decision-making authorization, as outlined in Chapters 4 and 6.

B. CURRENT ONTARIO LAW

1. Legislative Overview

• The provisions of Ontario law regarding who may act as a substitute decision- maker are outlined at length in the Discussion Paper, Part Three, Ch. II.

Who May Act as a Substitute Decision-maker

Under a Power of Attorney

An attorney must be:

1.Legally capable

2.Eighteen in the case of an attorney for property; sixteen for personal care An attorney for personal care may not be a person who

• Provides paid health, residential, social, training or support services to the grantor

• Unless that person is the grantor’s spouse, partner or relative

The PGT may only be appointed as an attorney with permission in writing.

Court Appointed Guardians

The court may not appoint:

1. A person who provides paid health, residential, social, training or support services to the individual, with limited exceptions

2. The PGT, unless the application proposes the PGT, the PGT consents, and there is no other suitable person who is available and willing to be appointed

The court must consider:

1.Whether the individual proposed as guardian is already acting under a POA for the person

2.The wishes of the person involved if they can be ascertained

3.The closeness of the relationship between the proposed guardian and the person

Replacement Statutory Guardians for Property

The PGT may consider applications from the following persons to replace the PGT as statutory guardian:

1.the person’s spouse or partner

2.a relative of the person

3.an individual holding a continuing POA for property for that person, if that POA was completed prior to the certificate of incapacity and did not give the attorney authority over all of the person’s property, or

4.a trust company, if the person has a spouse or partner who consents in writing.

The PGT must consider:

1.the legally incapable person’s current wishes if they can be ascertained

2.the closeness of the relationship between the applicant and the person

The PGT must be satisfied with the management plan submitted, and that the person is suitable

Health Care Proxies

The HCCA sets out a hierarchical list of those who may act for those who have been found incapable. These individuals must be:

1.capable with respect to the decision to be made

2.at least 16 years of age, unless he or she is the parent

3.not prohibited by court order from having access to or giving or refusing consent for this person

4.available, and

5.willing to assume the responsibility

The PGT shall make the decision if no person identified through the list meets the requirements

Families can bring a deep personal knowledge of the individual to guide them with decision- making and assist with the practical and emotional aspects of the task.

2. The Preference for Family

A review of the legislation quickly indicates a strong preference for family as SDMs. This is not surprising: the role is a difficult and demanding one which not infrequently spans many years and may be closely entwined with caregiving choices and responsibilities. Families can bring a deep personal knowledge of the individual to guide them with decision-making and assist with the practical and emotional aspects of the task. As well, they can often bring the profound commitment to the wellbeing of the individual that the role requires. It is a role imbued with trust and responsibility, and for many people, families are where they are most comfortable placing that trust and responsibility.

Nonetheless, some individuals either do not have family or friends who are appropriate, willing or able to take on this role, or would prefer that the role be carried out by someone with professional skill and objectivity. Trust companies will act under POAs for property for some existing clients, and will also sometimes be appointed as guardians for property in court proceedings. Lawyers and accountants will also sometimes agree to act under a power of attorney for property for their clients. Trust companies are, of course, heavily regulated institutions. Lawyers and accountants are guided by their professional standards and are subject to the oversight of their regulatory bodies, although not necessarily with respect to this role.

3. The Role of the Public Guardian and Trustee

The PGT may become guardian for a person who lacks legal capacity in two ways:

• statutory guardianships for property, as is detailed in Chapter 8, and

• appointment by the court, as is described in Chapter 7, most frequently following a “serious adverse effects” investigation.

In 2013-2014, the PGT was acting for only 21 clients under personal guardianship (3 on a temporary basis).491 The PGT notes that the Court will appoint it to make personal care decisions only “very occasionally” and in most cases to “remove the individual from a situation of harm or to prevent access by third parties who are abusing the person”.492 It is more common for the PGT to act as guardian of property, most frequently through statutory guardianships: the figures were provided in Chapter 8. 493

The PGT will also act as a decision-maker of last resort under the HCCA. In 2011- 2012, the PGT made 4,664 treatment decisions, under its responsibility to do so where there is no one who meets the HCCA requirements.494 The PGT may also consent (in rare circumstances) to appointment under a POA.

The Annual Reports of the PGT point to a steady and significant increase in the caseload of the PGT since 2000, both in absolute numbers and the number of clients as a percentage of Ontario’s adult population,495 likely reflecting Ontario’s aging population, as well as other demographic shifts such as smaller family sizes and increased family mobility. The PGT’s Annual Reports also point to increased complexity in the client files handled.496

What is important to note from the above is that the PGT acts as decision-maker in two broad circumstances: where there is no other appropriate, available and willing person to act, and where, as with statutory guardianships and guardianships resulting from investigations, there is perceived to be a need for an entity that can act quickly to prevent dispersal of property (as with statutory guardianships) or to end ongoing abuse, neglect or exploitation. This Chapter will focus on the PGT’s role as an SDM of last resort.

In addition to the demanding legal requirements, SDMs often face many practical, emotional and ethical challenges.

C. AREAS OF CONCERN

The LCO heard a number of concerns about the options for potential SDM appointees available to individuals. These growing challenges create pressure on existing institutions: they also create an opportunity to re-think who may fulfil the role of an SDM.

The complexities and challenges of the role: The role of an SDM can be extremely challenging. Some lawyers commented to the LCO that if people really understood what they were taking on when they agreed to act under a POA, far fewer people would be willing to do this. In addition to the demanding legal requirements, SDMs often face many practical, emotional and ethical challenges. Decisions may be high- stakes, involve complicated information and require rapid response. Decisions may well need to be made over the objections of the person who is intended to benefit over the long-term, so that the emotional costs may be high: for example, while admission to long-term care may be necessary, it is very often not a welcomed decision. Not infrequently, despite the guidance of the legislation, it will be far from clear what the “right” thing is to do in a particular circumstance. And as discussed in Chapter 10, there are relatively few practical supports for those taking on the role of substitute decision-maker.

In conversations with trust companies that act under POA for property or as guardians for property, these professionals also emphasized the challenges of the role, despite their expertise in financial management and the benefit of accumulated experience. The shifting nature of legal capacity, the complexity of the law, the difficulties of family dynamics and the challenging nature of some individuals’ needs all combine to make this a demanding role, even in the best circumstances.

It was pointed out to the LCO that the role of an SDM is a unique and complex role, requiring a very particular mix of skills. Individuals frequently ask lawyers or accountants to act under powers of attorney for property, assuming that those professional skills will provide adequate preparation for the role, but this is not necessarily the case at all.

Individuals who are socially isolated: As is discussed in Chapter 3, social and demographic trends are leaving more individuals without any family or friends who are both appropriate SDMs and willing to undertake the role. Throughout the consultations, the LCO repeatedly heard concerns about growing numbers of individuals who are socially isolated and have no appropriate person to act as an SDM if necessary. One long-term care home administrator with whom the LCO spoke indicated that she was aware of a long-term care home in which approximately one- third of the residents were having their property decisions made by the PGT.

Constrained options: Powers of attorney offer individuals the opportunity to choose for themselves who will act for them, should such assistance become necessary. It seems reasonable that individuals, knowing their own needs and their social circle, will be in the best position to make good choices about SDMs.

However, it was pointed out that these are, in most cases, constrained choices. Few of us have a wide circle of support from which to choose. The people who are closest to us, or who we most trust, may not have the skills to manage complex property issues or the temperament to make high stakes treatment decisions, or may live too far away to be able to effectively fill the role. Or the family dynamics or dependency relationships may be such that the person creating the POA may not be comfortable to name the person(s) who would be most effective, because others would be hurt or upset by the choice. In some cases, the individual must make the least inappropriate choice within a set of suboptimal options. These kinds of constrained choices may contribute to problems once the POA comes into effect, whether in the form of attorneys who exercise their duties poorly or abusively, or conflicts within the family regarding the exercise of the POA functions.

There are, therefore, individuals who are looking for SDM options beyond their family and friends, not because they are socially isolated, but because they simply have no one in their social circle with the necessary skills or temperament to fill this role, or because family dynamics make it impossible to fill the role without serious conflicts arising.

Many lawyers who work in this area told the LCO that they are very frequently asked to act under POAs. Some lawyers will take on this role, but many will not. Some trust companies reported being asked by clients to act as POAs for personal care, a role which they cannot take on, and which they would view as inappropriate for them even if it was permitted. Many stakeholders pointed out that there is a business opportunity here, and that there are organizations and individuals moving to fill the gap, but because there are no checks or oversight mechanisms, the quality of what is provided is extremely uneven.

The role of the Public Guardian and Trustee: Consultees appreciated the role of the PGT as a guardian of last resort. They also recognized the natural limitations of that role, in that the PGT is not, as presently constituted, naturally placed to develop the kind of ongoing, intimate relationships that are the best foundation for acting in a substitute decision-making role. It was generally felt that there was a better fit between property decision-making and the current nature of the PGT, than other types of decisions.

The personal care decisions gap: As was noted above, while the PGT does regularly make treatment decisions where no person on the automatic HCCA list is willing and available, it is quite rare for the PGT to be appointed as guardian of the person: at the time of the last annual report, the PGT was acting in this role for only 21 individuals in the province of Ontario. This likely reflects the deeply personal nature of this type of decision-making and an understandable reluctance to have government involved in this kind of role.

A number of service providers identified a gap in personal care decision-making. Trust companies pointed out that they not infrequently found themselves acting as a property decision-maker without anyone at all to consult regarding personal care issues, and identified this as a significant challenge in achieving the overall goals of the legislation. Long-term care home providers identified a similar gap, with residents of long-term care homes who had no one to engage on their behalf in any kind of broader care planning. Both types of service providers emphasized the importance of having someone who knows the person, cares about them, and can advocate on their behalf when necessary. As one long-term care home service provider put it, it is not just that there is no one to make decisions, but that there is no one who cares about the individual to make decisions.

The kind of caring that families can provide at their best is difficult to replicate. While the options discussed later in this Chapter may not be able to completely fill this gap, they may be able to provide some skill and knowledge to guide personal care for those individuals who currently lack any supports at all in this area.

The LCO was pointed to the growing number of businesses providing “elder care planning”, “transition planning” or “seniors care management” services as to some degree informally moving into this gap. These businesses may assist individuals or their families in developing and monitoring care plans; navigating the health, long- term care or community services systems and assisting with accessing services; providing counselling or advice where difficult choices must be made (for example, whether to move to long-term care or remain in the community); and providing practical supports to carry out decisions.

Abuse, Neglect and Conflicts of Interest: Chapter 6 dealt at length with concerns about abuse and misuse of substitute decision-making powers. Where there is vulnerability and an opportunity for personal gain, there will always be a risk of abuse. This is true whether the SDM is a family member, a friend or a professional. It is therefore always important, when considering who may act in a substitute decision- making role, to take into account conflicts of interest and the risk of abuse.

As was noted above, commentators raised concerns that because of the current shortfalls, individuals who are either without scruples or without skills are moving in to fill the gaps. One trusts and estates lawyer referred to the situation as a potential “Wild West” scenario, where individuals undertake SDM responsibilities as a business, without any meaningful oversight.

It’s just going to get done, anyway. I mean, there used to be a guy we called the public guardian and trustee of [a particular small city]. He had, like, what? A hundred powers of attorney? And he just sat up there managing a whole bunch of people’s money. You know, like, that’s what’s going to happen is, people are just going to go out there… They’re already doing it, but it’s just going to happen more. Are going to be out there in the market, doing it.

Focus Group, Trusts and Estates Lawyers, April 11, 2016

Stakeholders argued that new options ought to be structured to fill the gap without substantially comprising the safety of affected individuals.

One trusts and estates lawyer referred to the situation as a potential “Wild West” scenario, where individuals undertake SDM responsibilities as a business, without any meaningful oversight.

D. APPLYING THE FRAMEWORKS

Both of the LCO Frameworks for the law as it affects older adults and the law as it affects persons with disabilities identify a principle of promoting participation and inclusion. The definition of the principle in the Framework for the Law as It Affects Older Adults emphasizes the “right to be actively engaged in and integrated in one’s community”, as well as the importance of removing barriers of all kinds to such involvement, particularly for those who have experienced marginalization and exclusion. The Framework for the Law as It Affects Persons with Disabilities identifies the importance, not only of designing inclusively and removing barriers to participation and inclusion, but also of actively facilitating involvement.

The Final Report for the project on the law as it affects persons with disabilities noted,

Persons with disabilities have often experienced physical or social exclusion or marginalization, whether arising from attitudinal, physical, social or institutional barriers…. [P]ersons with disabilities continue to be pushed to the margins in a variety of social areas, including employment, education and community life. The principle of inclusion aims to redress this exclusion, and make persons with disabilities full members of their communities and society at large.497

The Report accompanying the Framework for the Law as It Affects Older Adults makes a similar point, drawing on the WHO’s Active Ageing Policy Framework’s broad approach to participation as including a right to be active in all aspects of community life.498

Without a person who has a duty to pay attention to their needs and wants, encourage their participation in decision-making to the greatest degree possible, and ensure that necessary decisions are made and communicated, these individuals are at risk of being not only misunderstood but of having their needs disregarded because there is no one to understand and communicate them.

Continued shortfalls in the inclusion of persons with disabilities and older adults in social and community affairs lie at least partially at the root of the lack of social networks and supports that some older adults and persons with disabilities face, and which manifest in a lack of willing, available and appropriate family and friends to act as SDMs.

The principle of fostering autonomy and independence includes, for older adults, “the right of older persons to make choices for themselves”, and for persons with disabilities “the creation of conditions to ensure that persons with disabilities are able to make choices that affect their lives”.499 In general, the principle of autonomy and independence points to the importance of promoting the ability of persons with disabilities and older persons to have and make meaningful choices about the appointment of an SDM. The current legislation reflects this principle in a number of ways. The emphasis in the legislative scheme on personal appointments reflects the importance of individuals choosing their SDMs for themselves. The SDA directs the PGT, when reviewing applications to replace it as statutory guardian, to consider the legally incapable person’s current wishes if they can be ascertained,500 and the Court is directed to a similar consideration in the case of court-appointed guardians.501

For isolated and marginalized individuals, the connection between the principle of participation and inclusion and that of independence and autonomy becomes very clear. Without inclusion in the community and the social supports and networks that provides, these individuals have no meaningful choice as to who will assist them with decision-making if that need arises, something that is central to their autonomy.

Consultees have raised grave issues regarding individuals who have no one to ascertain and speak for their personal care needs. Without a person who has a duty to pay attention to their needs and wants, encourage their participation in decision- making to the greatest degree possible, and ensure that necessary decisions are made and communicated, these individuals are at risk of being not only misunderstood but of having their needs disregarded because there is no one to understand and communicate them. This is an affront to the dignity of individuals who are not able to make decisions independently, but who nonetheless retain the right to be treated with respect and to have their values and preferences ascertained and taken into account.

As discussed above, issues related to choice of legal representative are not of concern only to those who are socially isolated or marginalized. Because of the role of SDM is complex and challenging, even individuals with thriving social networks may find it difficult to identify someone with the requisite skills, temperament and time to undertake this responsibility. For these individuals, expanding options for who may act as an SDM may also contribute to greater autonomy.

It is important to remember as well that even with expanded options, some individuals are always likely to have few choices – persons whose financial means are too limited to be of interest to for-profit service providers, and who are, through their circumstances or the nature of their disability, hard to serve and who require careful

A “market-based” approach to increasing choice of SDM may have an unintended side effect of reducing service to these most vulnerable individuals, unless appropriate attention is paid to ensuring that their needs are met in a professional and ethical way.

and compassionate attention. A “market-based” approach to increasing choice of SDM may have an unintended side effect of reducing service to these most vulnerable individuals, unless appropriate attention is paid to ensuring that their needs are met in a professional and ethical way.

As many have pointed out, any expansion of options must pay careful attention to the principle of recognizing the importance of security or facilitating the right to live in safety. Expanding options may promote safety and security, as individuals may not be constrained to appoint persons who they are aware may not have the skills or temperament to perform the role well, for lack of other options – or worse yet, have their decision-making default to inappropriate persons under the HCCA hierarchy.

However, as there is always risk associated with decision-making arrangements, it is important that options that are to be made available to individual be identified and designed in a way that carefully balances the benefits of increasing choice with risks of abuse or misuse. In particular, issues related to conflicts of interest and of oversight are important.

E. THE LCO’S APPROACH TO REFORM

The LCO’s recommendations are informed by five important considerations:

First and foremost, the LCO believes that anyone who lacks legal capacity and requires a substitute decision-maker to make necessary decisions should have meaningful access to one.

Second, individuals who lack or may lack legal capacity have a wide range of needs. For example, the needs of a wealthy senior with a complicated family structure, of a widow with a fixed income living in long-term care with her surviving family members half a continent away, or of a socially marginalized low-income person with a significant mental health disability are likely to be very different. Currently, the PGT may be the default option for all of them. A wider range of options may better serve their needs.

Third, while family remains important, family members are not always the best choices for SDMs. As has been emphasized throughout this Final Report, the role of SDM is a demanding one. Even loving family members may not be suited to this role. Current social and demographic trends accelerate the need to promote non- traditional options and approaches.

Fourth, the PGT has a vital role in providing professional, ethical and expert substitute decision-making for individuals for whom other options are not appropriate or available. There will likely always be some set of individuals for whom other options are not appropriate or available – for example, because they do not have funds to pay for services, or because the nature of their needs is too complex or demanding for most service providers. It is important that the PGT remain available to provide high quality decision-making services to such individuals.

Finally, there are risks of abuse and misuse of powers associated with substitute decision-making: an expansion of options for who may act must take careful account of these risks.

As throughout this area of the law, in implementing these approaches careful thought must be given to balancing respect for personal choice with the institution of adequate and appropriate safeguards. Because individuals must make choices with incomplete knowledge about their future circumstances, and because the very nature of the impairments that bring SDM arrangements into play reduce the ability of individuals to protect themselves against negative outcomes, the balance is especially fraught.

There will likely always be some set of individuals for whom other options are not appropriate or available – for example, because they do not have funds to pay for services, or because the nature of their needs is too complex or demanding for most service providers.

F. RECOMMENDATIONS

The LCO’s recommendations in this area have two broad objectives:

1. Supporting the development of trustworthy options for substitute decision- making, and

2. Providing a “safety net” for individuals for whom other substitute decision- making options are inappropriate.

1. Regulated Professional Substitute Decision-makers

Professional substitute decision-makers are an integral part of the legal capacity, decision-making and guardianship landscape in many jurisdictions. In the United States, state governments often have a much more limited role in providing last resort (or any) guardianship, and professionals fill this role for those who do not have family or friends to serve. In England and Wales, the Public Guardian and Trustee does not itself act as a guardian, but instead recruits and supervises a panel of professionals who provide this service.

Professional or for-profit substitute decision-makers may appeal to individuals for two main reasons:

1. Where individuals have no trusting relationship with an appropriate person who is willing and able to act on their behalf, professional SDMs may be an appealing alternative. In Ontario, some individuals may prefer a professional to the services offered by the PGT.

2. Some who have other options find the idea of a professional SDM appealing because their specialized focus gives professional SDMs the opportunity to develop experience and expertise in fulfilling this role, and they are independent of negative family dynamics.

Professional substitute decision-making (as distinguished from the services provided by the PGT) exists in Ontario. Current legislation explicitly enables individuals or institutions can act as SDMs for profit under POAs for property, although there is no parallel provision for personal care. Such professional substitute decision-making is commonly provided by:

1. Trust companies: Many trust companies provide highly regulated and expert SDM services to small numbers of clients. Trust companies generally offer their services as attorneys under a POA for property to only a limited range of existing clients, and so are not available to many individuals who might see professional decision-making representatives as a desirable option.

2. Regulated professionals: Individuals do appoint various professionals, most commonly lawyers and accountants, to act under their POAs for property. Such are guided in the role by the professional ethics, standards and oversight mechanisms associated with their profession, to the extent that they are applicable. As was highlighted earlier, anecdotally, this seems to be a growing practice. However, it is impossible to determine just how common this kind of service currently is in Ontario.

3. Others: Current legislation prohibits the Court from appointing as a guardian any person who provides health care or residential, social, training or support services to the incapable person for compensation, unless that person is also the incapable person’s spouse, partner or relative, and there are similar restrictions on who may be appointed to act as a power of attorney for personal care.502 However, where there is no conflict of interest, it is possible for individuals from a range of backgrounds to take on this responsibility.

In the Ontario context, there are currently a number of factors limiting the use of such professional services.

First, individuals who are seeking to appoint a professional as SDM have no easy way of finding such services or assessing their quality or reliability, very important factors in this context. Individuals may have to conduct extensive searches to find one that will act, and will have to determine for themselves whether that professional has the requisite skills and ethical compass. The lack of standard qualifications or training for professional substitute decision-making makes assessment difficult.

Secondly, the current absence of any meaningful oversight for most professional substitute decision-makers (the obvious exception being trust companies), may make this a less appealing option for some. Whatever the limitations of family or of the PGT, it may seem preferable to rely on the ethical and affective bonds of the one or the fundamental guarantees associated with services provided by government, as opposed to the unknown and potentially grave risks associated with unsupervised individuals motivated solely by profit.

Thirdly, there is no clear provision for professional SDM services with respect to personal care. As was noted above, several consultees identified a troubling gap in the provision of substitute decision-making assistance in the realm of personal care for individuals who do not have a relationship with someone who is willing and able to take on this role.

Finally, professional decision-makers are likely to appeal to a relatively small segment of those who require substitute decision-making: those with the financial means to make it reasonably remunerative for a professional to provide this type of service.

Notably, for both trust companies, lawyers and accountants, these types of services are just one part of a larger business plan.

Given social and demographic trends, professional substitute decision-making may become an increasingly important part of the landscape in this area of the law. This raises the question of whether steps should be taken to apply standards and oversight to such services, in order to increase the ease of access, make such services more appealing to the public, and prevent abuse of vulnerable individuals.

There may be significant risks associated with some forms of for-profit substitute decision-making. Unscrupulous for-profit substitute decision-makers may reduce their services and increase fees. Some may take the opportunity to commit outright theft. The impact of these risks is significant because the client may not have the ability to terminate the arrangement or to effectively supervise the substitute decision- maker. Absent some kind of oversight regime, there may effectively be no review or monitoring of activities of some kinds of professional SDMs. Experience has demonstrated that these risks are real: in the United States, where professional fiduciary programs are very common, there have been repeated concerns about unethical behaviour on the part of some subset of providers.503

Responses to the Interim Report indicated some division of opinion on this issue. The 2016 submission of the Advocacy Centre for the Elderly expressed clear opposition to any expansion of professional SDM services:

As the Interim Report has identified, for-profit substitute decision-making contains significant risks. Maximization of profit may be seen by these entities as more important than acting in accordance with their clients’ best interests. ACE has heard from callers when lawyers or accountants have acted as attorneys for property and charged significant fees to incapable clients. While the mechanism for for-profit substitute decision-making currently exists in the property management sphere, there is no need for a recommendation to make it easier for professionals to act as attorneys for property.504

Others, however, took the position that these types of services exist now and can be expected to expand in light of social and demographic trends: the question is not whether they should exist, but whether efforts should be made to regulate and oversee them, in order to prevent the kind of abuse that is easily foreseeable without such regulation.

In terms of the number of disputes we currently have, a lot of them erupt because of the fact that there wasn’t a good independent choice. Or the people that had been appointed don’t really know what their roles are. So a lot of it is really due to, you know, the fact that we don’t have a very robust system. Of having well-trained, competent, capable people to take on these roles that people can choose.

Focus Group, Trusts and Estates Lawyers, April 11, 2016

On balance, the LCO supports a well-supervised and regulated program for professional SDMs for the following reasons.

First, a well-designed program could support a broader range of trustworthy options for persons to act as SDMs, and thus could meet a need for expert and professional SDM services for those who have the means to pay for such services and who either do not have appropriate trusted others to fill this role or who prefer to have such assistance provided by a neutral and expert third party. It would provide individuals with a practical alternative between the appointment of family and friends, and the use of the PGT, and help to ensure that the resources of the PGT can be focussed on those who most truly need its services. That is, it would expand choice so that the system can meet a wider range of needs in a more tailored way.

Second, the SDA essentially already permits for-profit substitute decision-making for property. Because of the extreme vulnerability of persons to whom such services are provided and the lack of any meaningful external oversight of personal appointments, the risks of abuse in these scenarios are very high. Given that social and demographic trends point towards expanding use of these types of services, regulation will become increasingly important. Several stakeholders highlighted, in discussing these issues, the spate of scandals related to these services in the United States in the late 1980s: these kinds of problems could certainly happen here.

The following section identifies what the LCO believes to be minimum requirements for such a program.

Minimum Requirements

Careful consideration must be given to the establishment of safeguards for this service, both as a means of protecting users and to develop this as a credible alternative to the status quo in the minds of potential users.

Stakeholders responding to the Interim Report emphasized the following three key elements of any regime for professional SDMs:

1. Clear and thorough standards for the provision of such services,

2. Minimum levels for knowledge and skills, and

3. Meaningful oversight, with effective recourse in cases of abuse or violation of standards.

The LCO has examined the experience in the United States for lessons learned…

As was briefly referenced above, it is very common in the United States for guardianship to be exercised by corporate employees or by other professionals or practitioners.505 The LCO has examined the experience in the United States for lessons learned in this respect. The regimes for regulating professional guardians/professional fiduciaries vary considerably from state to state, from very informal to highly regulated. Some of the potentially useful and applicable safeguards and structures associated with these programs, as operated in larger states with populations more comparable to those of Ontario, are identified below.

American regulatory regimes for professional guardians tend to be designed to capture those individuals and organizations that are carrying out these roles as a primary business, and to exclude family members or friends who are receiving some compensation for their responsibilities, or lawyers or other professionals who may occasionally take on this responsibility. Generally, regulation applies to those who are providing services for compensation to multiple individuals.

The National Guardianship Association (NGA) in the United States, founded in 1988, plays an important role in this area,506 with a mission to “advance the nationally recognized standard of excellence in guardianship”. The NGA has developed national practice standards for individuals and for agencies. It has advocated for guardianship certification and has created a Centre for Guardianship Certification, through which individuals may be certified as a National Certified Guardian or a National Master Guardian. It provides considerable professional development opportunities for guardians. Should government decide to proceed with the development of professional fiduciaries, the work of NGA may be of considerable assistance, for example, as a source of standards.

Pre-certification requirements: While small jurisdictions may treat professional guardianships relatively informally, relying on court supervision and informal networks as safeguards, larger states where there are many professional guardians acting tend to have relatively thorough pre-certification requirements.

Education, training and certification: Many states require completion of education or training, completion of a certification exam, or both. For certification of a professional guardian, Florida requires guardians to complete a minimum of 40 hours of training. They must also score a minimum of 75 per cent on a Professional Guardian Competency Examination, which is administered by the University of South Florida, or receive a waiver from the Statewide Public Guardianship Office. In California, applicants must complete 30 hours of education in approved education courses.507 In Texas, applicants are required to have at least two years of relevant experience or have completed an approved course, and to successfully pass an approved exam after no more than four attempts.508

Credit and criminal history checks: For certification, guardians may be required to undergo a criminal records check, a credit check or both. Florida requires all professional guardians to provide credit and criminal records checks at their own expense, as part of their requirements for practice.509 California stipulates that the Professional Fiduciaries Bureau not issue a license to any person who has been convicted of a crime that is “substantially related to the qualifications, functions, or duties of a fiduciary”, who have “engaged in dishonesty, fraud, or gross negligence in performing the functions or duties of a fiduciary”, who have been removed as a fiduciary by a court for breach of trust committed intentionally, with gross negligence, in bad faith, or with reckless indifference, or who have “demonstrated a pattern of negligent conduct”.510 Texas includes criminal record provisions, but not credit checks.511

Bonds or insurance: Some states require guardians to have insurance or to post bonds. For example, in Florida, all professional guardians must post a blanket bond of a minimum of $50,000 that covers all wards under the guardian’s care.512 In Washington State, the professional guardian must post a bond in an amount determined by the court for each ward, though that bond may be waived for clients with very low levels of assets.513

Registration: Where certification is required, a registry of certified guardians is generally maintained. For example, in California, licensing is carried out by the Professional Fiduciaries Bureau. The PFB maintains a list of qualified, licensed private professional fiduciaries, which can be found on their website.514 It is also required to provide information regarding any sanctions imposed on licensees, including, but not limited to, information regarding citations, fines, suspensions, and revocations of licenses or other related enforcement action taken by the bureau relative to the licensee.515

Ongoing duties and responsibilities: In addition to pre-certification requirements, states may also impose ongoing duties to ensure standards and enable monitoring.

Continuing education: Following the completion of the initial 40 hours of mandatory training, professional guardians in Florida must complete 16 hours of continuing education every two years. The Florida Guardianship Association approves continuing education activities for this purpose.516 Similarly, in California, to renew a license, applicants must complete 15 hours of continuing education,517 in an education course approved by the Professional Fiduciaries Bureau.518

Regular reporting: Professional guardians in Florida must register annually with the Statewide Public Guardianship Office. As part of this registration, they must provide regular credit and security checks for themselves and their employees, and evidence that they have completed their required continuing education requirements.519 For each individual to whom they provide services, both an Initial Guardianship Report and an Annual Guardianship Plan must be filed. The Annual Guardianship Plan includes an Annual Accounting Report, as well as information about the residence, social condition and mental and physical health of the ward. 520

In California, licensees are required to keep complete and accurate records of client accounts, and to make those records available for audit by the bureau.521 They must also file an annual statement with the PFB, which provides a range of information, including whether the licensee has been removed as a conservator, guardian, trustee, or personal representative for cause; the case names, court locations, and case numbers for all matters where the licensee has been appointed by the court; whether she or he has been found by a court to have breached a fiduciary duty; any licenses or professional certificates held by the licensee; any ownership or beneficial interests in any businesses or other enterprises held by the licensee or by a family member that receives or has received payments from a client of the licensee; and whether the licensee has been convicted of a crime.522

In Texas, guardians must file an annual report indicating the number of wards under their care, the aggregate fair market value of the property of all wards, money received from the State of Texas for guardianship services and the amount of money received from any other public source. Following certification, guardians must submit annual renewal applications.523

Professional standards: Florida sets standards for profession guardians through its statute. For example, guardians must visit each ward once every four months to ensure that their needs are being met.524 In California, the Professional Fiduciaries Bureau is responsible for the development of a code of ethics for fiduciaries.525 In Texas, the Judicial Branch Certification Commission is responsible for the creation of the Minimum Standards of Guardianship Services, with which guardians must comply.

Interestingly, these designation and oversight mechanisms for professional SDMs are in many ways reminiscent of those employed for Capacity Assessors designated under the Substitute Decisions Act, 1992, as described in Chapter 5. To be included in the list of designated Capacity Assessors maintained by the Capacity Assessment office, Capacity Assessors must meet minimum educational requirements, complete a qualifying course on which they are evaluated, complete regular continuing education courses, comply with government standards, and regularly submit copies of assessments for review and feedback. The Ontario experience with designated Capacity Assessors may therefore be valuable in designing a regulatory regime for professional SDMs.

The LCO believes that minimum educational and training requirements for certification, together with ongoing professional development obligations are a sensible approach to ensuring that professional fiduciaries do indeed have the specialized skills which are one of the main proposed benefits of such a scheme. Clear standards are a basis for accountability: as was noted above, the standards created by the National Guardianship Association may inform the development of standards for an Ontario system. As well, recording and reporting requirements are a basic mechanism for oversight where professionals are handling funds for vulnerable individuals.

It must be recognized that there are incremental“costs” associated with any form of regulation…

Appropriate Form of Regulation

A final question is the form which regulation of professional SDMS should take. One option is a licensing regime, in which professional decision-making representatives could not legally practice without meeting specified requirements; another is a certification approach, in which professionals may voluntarily seek certification from a self-governing entity, with certification providing reassurance to the consumer that the person meets certain qualifications and is subject to the code of conduct, rules, and other guarantors of safety and quality provided by the certifying agency.

The Manitoba Law Reform Commission (LRC), in its report on Regulating Professions and Occupations526 proposes a cost-benefit analysis when considering whether to regulate an occupation, weighing the need for protection of the public from the improper performance of the service against the costs of regulation.527

It must be recognized that there are incremental “costs” associated with any form of regulation, whether it be licensing, certification or some other form of regulation. There are obvious costs, such as the resources required to administer the regime (for example, the costs associated with operating the regulatory office) that will have to be borne either by the taxpayer or indirectly by the purchasers of the service depending on the regulatory model. The Manitoba LRC also pointed to less often considered costs, such as increased prices for consumers: a requirement that no one but a licensed professional can perform a service limits competition and essentially creates a monopoly of those who can offer the service, thereby adversely affecting the pricing for the service.528 This can create a barrier to access for those less financially able. A certification regime will limit competition less than licensing and thereby be less costly, as consumers are able to hire either a certified or uncertified person to do the work. The Manitoba LRC therefore recommended that licensing should be used “sparingly and cautiously”, and only where the threatened harm to the public from inadequate performance of the service is serious.529

The LCO believes that a professional decision-making representative regime should be subject to licensing, rather than simply certification. As has been highlighted throughout this Final Report, there are significant and substantial risks of harm that are intrinsic to substitute decision-making, due to the combination of the population being served, the basic rights at issue, and the access substitute decision-making provides the SDM to financial or other benefits of the individual served. This recognition underlies the very existence of Ontario`s legal framework in this area, and the role allocated to the PGT. The combination of these attributes with the profit motive indicates a need for great caution and care. Further, without regulation and oversight, professional SDMs are not likely to be taken up to any great degree, due to valid consumer concerns about abuse. While regulation may increase costs of access, the LCO proposes that the PGT remain responsible for service for those who are not best served by other means: the regulated profession should not be the sole means of access to these kinds of services, but part of a mix that will continue to include families, the PGT and trust companies, which are already thoroughly regulated.

A final question is who should be responsible for oversight. The two main options are government, either through a government Ministry or an agency such as the Financial Services Commission, or self-regulation, such as the Law Society of Upper Canada or the regulated health professions provide.

It should be noted that while self-regulatory entities are funded by the members that they regulate, direct oversight by government or a government agency may be funded by, for example, the levying of fees to regulated individuals. That is, a choice between models is not automatically a choice between self-funding or taxpayer funding.

While all models of regulator have government oversight, self-regulatory models are one step removed from this oversight compared to situations where the government or one of its agencies is directly regulating the activity. The Manitoba LRC in its 1994 report examined the advantages and disadvantages of the self-regulatory model. It identified that in some circumstances, the profession itself may be in the best position to create the rules that would govern the profession, saying, “Compliance [with those rules] may also be more likely if self-government results in a sense of community among practitioners which strengthens a commitment to high standards of competence and ethical conduct”.530 This more clearly applies to professions that are relatively “mature” in the sense of there being an established community of persons practising the particular activity, a history of ethical conduct and a well-understood and established standard of practice, than to a situation such that under consideration, where a new profession is essentially being created.

As well, the Manitoba LRC notes that for self-regulation to work, there must be a “critical mass” of practitioners to pay for and take on the tasks necessary for a self- regulatory entity to function. The Health Professions Regulatory Advisory Council, which provides advice to the Minister of Health and Long-Term Care if so requested on whether unregulated professions should be regulated,531 considers whether “the practitioners of the profession are sufficiently numerous to support and fund, on an ongoing basis, the requisite number of competent personnel to enable the regulatory body to continue to discharge its functions effectively.”532

A key disadvantage of self-regulation identified by the Manitoba LRC is the potential for the regulator to experience conflict between the self-serving interests of the profession versus the broader public interest. In this regard, the Health Professions Regulatory Advisory Council examines whether “the profession’s leadership has shown it will distinguish between the public interest and the profession’s self-interest. Regulatory colleges are mandated to privilege the former over the latter”.533

In examining the American experience in the larger states, most have some type of direct government oversight of professional guardians. The state of California has established a Professional Fiduciaries Bureau, to license, oversee and regulate professional fiduciaries.534 In Florida, the Statewide Public Guardianship Office is responsible for registration of Professional Guardians and for receipt and review of annual reports and Guardianship Plans. In Texas, oversight of professional guardians is carried out through a branch of the judiciary, the Judicial Branch Certification Commission, which is also responsible for oversight of other professions associated with the courts, such as court reporters, process servers and court interpreters.535

Overall, it appears to the LCO that in this situation, where the intent of regulation is essentially to establish and support the development of a relatively new or little considered service or profession, a self-regulatory approach is not particularly practical, at least not at this point in time, and that some form of direct regulation, perhaps similar in some key aspects to that developed for Capacity Assessors, should be developed.

THE LCO RECOMMENDS:

46: The Government of Ontario conduct further research and consultation towards the goal of establishing a dedicated licensing and regulatory system for professional substitute decision-makers that includes the following attributes and safeguards:

a) Licensing and oversight focus on those in the business of providing these services for multiple individuals;

b) Licensing and oversight be provided by the provincial government or through a government agency potentially funded through fees;

c) Licensed professional substitute decision-makers be permitted to make both property and personal care decisions, and to be appointed either personally or externally;

d) The oversight regime address the following safeguards and assurances of quality:

i. Ongoing requirements for skills and training;

ii. Ongoing professional development requirements;

iii. Requirements for credit and criminal records checks;

iv. Quality assurance and conduct standards, including prohibitions on conflicts of interests;

v. Record keeping requirements;

vi. Annual filing requirements; and

vii. Requirements for bonds or insurance.

2. Developing a Role for Community Organizations

Should Community Organizations Act as Substitute Decision-makers?

For-profit professional SDMs may provide appropriate options for individuals with sufficient property to justify the expense. It has been suggested that community organizations could provide an additional non-profit option. As organizations that are close to the community, provide a range of supports, and that have the ability to develop a deep understanding of the contexts and needs of the particular populations they serve, community organizations may have the capacity to provide a more personal and holistic approach to the role of SDM for their populations, and to serve populations that would not be able to access for-profit services or that might be challenging for families to adequately support.

Community organizations in Ontario do already act as trustees for benefits under the Ontario Disability Support Program,536 as well as for Canada Pension Plan (CPP) and Old Age Security (OAS) benefit.537 In some ways the function of these informal trustees are analogous to the duties that may be undertaken by a guardian for property or a person acting under a POA for property, although it should be noted that these trustees are dealing only with one relatively limited income source, and that the nature of the ODSP program creates some opportunity for monitoring and for reasonably timely corrective action should an informal trustee misuse funds. While concerns have been raised about various aspects of the ODSP informal trusteeship provisions, including insufficient oversight and a lack of effective recourse for individuals to challenge the appointment of a trustee, the LCO has heard that some community organizations are able to provide very good informal trusteeship services as part of a more holistic package of services that they provide to clients that they know well and regularly interact with. This is certainly the intent of the federal Supporting Homeless Seniors Program, which aims to assist vulnerable seniors in receiving their federal income benefits by expanding “the capacity of reputable organizations and municipalities already on the front-lines of service delivery to homeless seniors to help them apply for and administer their CPP, OAS and/or GIS benefits”.538 It is also true, however, that community organizations may be reluctant to take on this role due to pressures on budgets or staff.

The Bloom Group, operating in British Columbia as a provider of mental health and supportive housing, emergency shelters for women and children, and hospices, largely in Vancouver’s Downtown Eastside,539 is an example of a community organization providing this type of day-to-day decision-making, as a trustee for federal pension programs. It receives referrals from the British Columbia Public Guardian and Trustee and from social services.540 In the fiscal year 2013-2014, the Bloom Group managed the finances of 858 individuals, described as “seniors who are vulnerable to financial abuse and people who have physical and/or mental constraints”.541 The organization does charge a fee for its services, but notes that it keeps its fees as low as possible, so that individuals with limited incomes can access these services, and that it invests the fees back into the program. The program’s Adult Guardianship Workers work with mental health teams, care facilities and other community groups as necessary. The Adult Guardianship Workers provide the following services, among others:

• development of a functional budget and plan for debt reduction, in co-operation with clients, based on income, monthly expenditures, debts and saving for future needs;

Some community organizations that the LCO spoke with during consultations indicated that they saw a role as SDM as confusing their mandate, and therefore inappropriate.

• bill payments such as rent, meals, utilities and pharmacy;

• facilitation of income tax filing and filing back taxes;

• liaison with community care workers to provide financial support to, and for, clients when appropriate;

• monthly statements upon request; and

• application to all possible income such as Guaranteed Income Supplement and the Disability Tax Credit.542

Some community organizations that the LCO spoke with during consultations indicated that they saw a role as SDM as confusing their mandate, and therefore inappropriate. These kinds of concerns were reiterated by the Advocacy Centre for the Elderly in their 2016 submission:

day-to-day lives of the people who live within their walls or use their programs. Where these organizations provide accommodations (i.e. not-for-profit long- term care homes), they may be involved in providing health care, personal support services, food, and transportation for these individuals. This creates a significant conflict of interest where they are providing personal care services and making decisions about paying bills for, and accessing, these same care services. In ACE’s experience, this is fertile ground for abuse given the limited ability to monitor the provision of these services. It was this recognition of conflict that led to the SDA prohibition of those who provide health care, residential, social, training or support services for compensation from acting as attorneys for personal care for the person.543

The draft recommendation in the Interim Report received support from a significant number of organizations, including ARCH Disability Law Centre, the Mental Health Legal Committee, and OASIS (Ontario Agencies Supporting Individuals with Special Needs). A number of community organizations expressed some interest in such a role, seeing it as beneficial to their clientele and an extension of work that they already do. One example pointed to was the Canadian Hearing Society’s General Support Services program, which provides advocacy services and life supports to individuals.544 Others pointed to the evolution of person-centred service approaches.

Thinking about that from our perspective, I won’t speak for the agency, but we have a really, you know, person-centred approach to providing services, and we build supports around people, and there is no stranger who supports anymore. I mean, relationship is developed and supports are quality, you know, based on what the person needs, so we already have, you know, the basis of what’s in the best interest of the person and we support people to make their own decisions already. … Helping them make decisions might, you know, be a conflict of interest, but in an agency like our size, we could put in checks and balances, you know, like, counter that…. Because we have that already built into our agency and services and supports that we provide for people and that, I think, is such a critical piece to recognize legally. Why do we have to branch off and go to a stranger for decision-making care when we have this wholesome, really positive approach to good outcomes?

Focus Group, Developmental Services Sector, October 17, 2014

City of Toronto consultations with service providers indicated that this role for community agencies was feasible if implementation was carefully addressed, and saw a “huge opportunity” here to bring services and supports to populations with specific needs, including cultural, religious and linguistic groups, youth, LGBT persons, and persons with different types of disabilities. This group highlighted the opportunity to build on existing practices and expertise: “Some agencies already have expertise or infrastructure related to this role, or do “bits and pieces”. For example, case managers already help with day-to-day decision-making, including budgeting, checking in and following up.”545

Those organizations and stakeholders indicating interest in a role for community organizations did point out that careful thought would have to be given to conflict of interest issues and to the limits of their expertise. While a key potential benefit of appointing a community organization to serve as SDM for an individual is the holistic approach that such an organization might be able to bring to this role, the flip side of this is that a community organization that provides social services and also acts as an SDM may experience at least potential, if not actual, conflicts of interest between these two roles. There is a risk that the agency may make decisions that inappropriately take into account the needs of the agency as a service provider, in a way that may not be in the best interests of the person for whom they are acting. A review of American public guardianship systems, in which a “social service agency” model for the provision of last resort guardianship is very common, succinctly expressed this tension:

At first blush, the social service agency model might seem the most logical placement for public guardianship in that staff are knowledgeable about services and have networks in place to secure services. However, this model presents a serious conflict of interest in that the guardian cannot objectively evaluate and monitor the services provided. Nor can the guardian zealously advocate for the interests of incapacitated persons, including lodging complaints about the services provided. The filing of an administrative action or a lawsuit may be stymied or prevented entirely.546

There were some suggestions that community organizations could perhaps partner with the PGT, with the organizations making day-to-day decisions for their clientele, but with the ability to refer decisions that were beyond their expertise or raised conflicts of interest back to the PGT for determination.

If I was going to invest some money into the system, I would invest it in helping the Guardian and Trustee clear some of the [unclear]. Like you know, they have so many people where they’re you know, managing finances for. And, like again, do you need a pair of pants or not? Like, that stuff can be done in the community. You know, surely there’s somebody that you have, like, say you have the mechanism through the ODSP trustee … So get those people and let them focus like they’ve done.

Focus Group, Service Providers for Individuals Living with Dementia, October 21, 2014

In the City of Toronto consultation with service providers, it was suggested that the PGT structure and mandate be revamped to enable it to work in partnership with community agencies in this aspect of its role.547

Another suggestion was that community organizations could perhaps partner with trust companies to serve some clients, to provide not only checks and balances but a more comprehensive set of skills. Clear standards for professionalism and ethics would also be of assistance.

I think it’s about professionalism and training. Yes, there can be a conflict, there’s no question, but typically if you’re looking for a power of attorney for property when it is being assigned to a bank you’re going to assume the conflict has been removed but the bank or trust company still needs direction from someone in terms of how it is done. That is a role that [our organization] plays often and again it needs to be bigger than that to be able to have professional guidance of what someone’s needs are…. So there’s a risk of conflict but I think it can come back to who is holding that role, by profession, by experience and by training.

Focus Group, Advocacy and Service Organizations, October 3, 2014

One lawyer thought that there could be merit in examining social enterprise models to meet this need:

[I]f you could partner a community agency with some kind of for-profit model, so that you were doing some of both. And your profits were being used to subsidise the work for the people who can’t afford it. You might be able to come up with some kind of model.

Focus Group, Trusts and Estates Lawyers, April 11, 2016

Others cautioned against the spectre of, for example, for-profit retirement homes setting up “friendly” associated non-profit organizations to undertake decision- making for residents, a set-up which would create significant conflicts of interest and levels of risk for residents.

It should also be noted that the PGT, trust companies and the proposed professional SDMs all are in a position to develop expertise in the role of SDM, because it is a core area of focus for those who carry out it. While community agencies might bring deep knowledge of particular areas – for example, the needs of persons with mental health disabilities and the systems that they must navigate – they may not naturally develop a profound knowledge of the legislative scheme and their responsibilities under it, and how to best fulfil these, although the example of the Bloom Group does highlight the capacity for community agencies to develop such specialized expertise.

The LCO’s Final Report in its project on Capacity and Legal Representation for the Federal RDSP considered the appropriateness of enabling community agencies to act as legal representatives for RDSPs. Noting that organizations are commonly named as trustees for ODSP, CPP and OAS, and that the Saskatchewan Powers of Attorney Act enables the appointment of corporations as attorneys under a POA, the LCO also recognized the risk posed by conflicts of interest and the significant responsibilities attendant on acting for multiple individuals. The LCO made the following recommendations:

1. The Government of Ontario recognize that community organizations are eligible to act as RDSP legal representatives where they are approved to provide services to adults with disability through designated Ontario ministries.

2 . The Government of Ontario develop and implement a process for a designated government agency to approve the eligibility of community organizations to act as RDSP legal representatives, where they are not approved under Recommendation 6. The government agency be required to maintain a list of approved community organizations.

3. The Government of Ontario require that community organizations appointed as RDSP legal representatives under Recommendations 6 and 7 develop and implement a management policy with procedures to do the following:

a) maintain separate records of transactions respecting each beneficiary’s RDSP;

b) undertake periodic review of each beneficiary’s records; and

c) ensure that a suitable employee has clear signing authority to represent the community organization in transactions with a financial institution at all times.548

The responsibilities of a community organization acting as an SDM for property or personal care would be considerably broader and more complex, as well as entailing more risk to the individual, than are roles as trustees or as legal representatives for the purposes of opening and holding an RDSP account.

It is the view of the LCO that community organizations could perform a valuable role in relation to decision-making, given their specialized knowledge of particular communities and their ability to develop ongoing relationships with their clients. For example, community organizations with deep roots in particular disability communities may be well placed to understand the needs, options and circumstances surrounding common types of decisions. For members of certain ethno-cultural communities, community organizations might aid in interpreting the concepts, practices and goals of decision-making in a culturally appropriate manner. However, the role of community organizations in decision-making should be tailored both to the expertise and to the existing responsibilities of these organizations.

It would not be appropriate, for example, for community organizations to be making end of life or other major health decisions, or managing the investments of clients: these kinds of decisions lie beyond their roles and skill sets. However, community organizations, as a number of participants in the consultations noted, are well-placed to assist clients with day-to-day decision-making. They also may be particularly well place to address the personal care gap identified earlier in this Chapter, assisting individuals with identifying and accessing services and supports to meet their life goals and making decisions about lifestyle and day-to-day activities. Further, these community organizations may have considerable expertise in assisting individuals in identifying and accessing services and programs and in assisting with practical choices. Practically speaking then, the role of community organizations then might include basic budgeting and bill payment, assistance with application to government programs or services, arranging for support services, and personal care decisions related to nutrition, clothing, hygiene and daily activities.

If, as the LCO has recommended, an accessible means is created for application to a tribunal for appointment as a representative for single decisions, a system could perhaps be envisioned in which community organizations could manage day-to-day decisions related to personal care and property, with health care decisions defaulting to the PGT under the HCCA and the relatively rare major decisions related to finances or personal care or situations of conflict of interest managed through the single application process. Alternatively, the suggestions regarding partnerships between the PGT or trust companies and community organizations could be explored.

Standards and Safeguards

Stakeholders identified a number of key elements necessary to an effective and appropriate role for community agencies in substitute decision-making, including clear standards, partnership approaches, and meaningful oversight mechanisms.

Clear Standards: Submissions broadly emphasized the importance of clear standards to promote consistency, ethical practice, and quality:

ARCH believes that this recommendation can be substantially strengthened by highlighting the need for provincial standards to be applied if community organizations take on a larger role in day-to-day decision-making. Without clear provincial standards and expectations, it is likely that the level and quality of decision-making support provided by community organizations will vary greatly across the province. 549

Standards should address such matters as metrics for service provision, conflicts of interest, and processes for responding to misconduct. It was commented that, because many agencies have experience with similar types of work, development of standards of care and scope of responsibility can build on existing models. Careful attention to the potential tension between the need for flexible delivery models and the need for strict accountability frameworks and standards will be necessary.

Training and Skills Development: Because of the unique aspects of this role, agency staff would benefit from training and skills development in this area. This is an area in which government may be in a position to provide the support. It was also suggested that interagency partnerships could be beneficial, so that agencies with successful program models can provide training and mentoring for others.

Partnership Approaches: As has been highlighted throughout this section, partnership approaches, whether between agencies or between agencies and government, can assist in increasing reach and access, capacity building and oversight, and quality assurance. Community agencies emphasized the importance of receiving adequate support from government in taking on this role.

Accountability and Oversight: As with the proposal to regulate professional for-profit SDMs, strong accountability and oversight mechanisms will be essential to the viability of this new role for community agencies. Stakeholders saw this as including:

• some process for selecting and qualifying community agencies;

• reporting requirements, which are tied to clear standards;

• some mechanism for regular auditing of activities; and

• some designated means for resolving disputes.

Questions of accountability and oversight are closely connected to issues of liability: without a clear and fair framework surrounding liability, it is unlikely that community agencies would see themselves as in a position to move forward with this role. Some models for accountability and oversight are briefly described below.

Appropriate Form of Regulation

It is a challenge to develop an effective model to engage community organizations appropriately in substitute decision-making. In considering the best way to structure appointment of community agencies to act as SDMs, it is important to remember that most community agencies are relatively small, and are already operating at capacity.

Because there is always a risk of abuse or misuse of substitute decision-making powers, there must be meaningful screening and oversight of organizations seeking to act as SDMs. However, community agencies may have considerable difficulty in complying with complex screening or oversight requirements, particularly if they are not intending to act for a significant number of clients and therefore do not develop deep knowledge of these systems.

In the United States, there are many non-profit organizations that have qualified as professional representatives under the rules of their particular states, and provide this type of service to those that require it. Some organizations are dedicated entirely to this type of work,550 while others carry out this role as one part of a broader mandate. This approach has the benefit of simplicity: rather than multiple approaches to identifying SDMs, there would be a single, consistent licensing approach. However, it may not be reasonable to require long-established non-profit organizations to undergo the same degree of process and scrutiny as a for-profit entity with no established track record of service or expertise. Further, the needs and concerns of a non-profit organization that wishes to include this role as one part of its supports to the community it serves will be different from those of a specialized for-profit entity. Certainly, while a specialized non-profit entity may appropriately seek licensing as a professional fiduciary, able to address the full range of decisions required for clients, this process may not be appropriate or necessary for community agencies that may wish to provide substitute decision-making only for daily decisions as part of its broader service role.

Further, if, as suggested above, the substitute decision-making role of community organizations is limited to day-to-day decision-making, rather than major decisions about accommodation, health care, or investments, the type and extent of oversight will differ from that required for entities taking on more extensive roles.

Three options for enabling community organizations to take on this more limited role while providing adequate screening and oversight are identified below.

A statutory amendment could permit the appointment of community agencies to this role. In Saskatchewan, The Powers of Attorney Act permits the appointment of corporations other than trust corporations as attorneys under a power of attorney.551 This provision was adopted in 2002, after the Law Reform Commission of Saskatchewan recommended that the appointment of corporate attorneys be permitted under the law, so that advocacy groups and “not-for-profit organizations dedicated to assisting vulnerable adults” would be able to act as attorneys.552 In British Columbia, an exemption under the Financial Institutions Act allows the Bloom Group to act as a trustee for its clients, as described above.553

The Public Guardian may directly delegate responsibilities to one or more community organizations. The State of Florida, in addition to a professional fiduciary system, has a public guardianship program for those who cannot pay for guardianship services. The Statewide Public Guardianship Office (SPGO) delegates public guardianship responsibilities to a range of non-profit organizations operating in various locales. To receive a contract, organizations must meet a range of criteria related to professional training, registration, knowledge, staffing and avoidance of conflicts of interest. 554 A 2009 review of Florida’s public guardianship program concluded that it was highly cost-efficient,555 but also noted that there was a conflict of interest inherent in the program in that the model “puts social services providers in the position of consenting to or refusing their own services”.556

The review of American public guardianship programs referenced earlier highlighted that it is increasingly common for public guardianship services to be “contracted out”, and expressed reservations about the practice:

Delegation of the decision-making powers of the Public Guardian and Trustee would raise challenging questions of legal liability, oversight and risk management.

Arguably, the “contracting out” approach allows states to experiment with various models of public guardianship service provision tailored to the needs of a particular region. However, this practice is not without peril and presents a service efficiency and effectiveness conundrum. Public administration literature indicates that contracting out for services is appropriate when the services of government are discrete (e.g., repairing potholes), yet, when the services of government are highly complex, as with public guardianship, services are best provided by a governmental entity. Under the “privatization premise”, contracting of this nature may pose a substantial threat to the provision of public guardianship services due to attenuated and unclear lines of authority, i.e. accountability.557

Delegation of the decision-making powers of the Public Guardian and Trustee would raise challenging questions of legal liability, oversight and risk management.

Consideration would also have to be given to the funding of the services to be provided.

Government may designate community organizations to act as SDMs. In Saskatchewan, The Adult Guardianship and Co-decision-making Act permits the Minister to designate corporations, agencies or categories of these as eligible applicants for the role of substitute or co-decision-makers, and non-governmental organizations such as the Saskatchewan Association for Community Living, have been appointed as co-decision-makers or guardians through this means.558 In practice, such appointments are extremely rare.559 Organizations may find it challenging to take on these demanding roles without additional supports, training and resources.

England and Wales have adopted a similar approach on a broader scale. In that jurisdiction, the Public Guardian and Trustee does not act as a guardian (deputy) of last resort. Rather, the Public Guardian and Trustee is responsible for maintaining a “panel” of individuals and organizations who are willing and appropriate to serve as deputies where necessary. Where a “last resort” deputy is needed, the Court of Protection may select a deputy from this panel.560 The panel at this point consists largely of lawyers, but does include some community organizations, and the Public Guardian and Trustee has indicated its commitment to “diversifying” its panel to include a wider range of skills and a broader set of options to meet the diversity of individual needs.561 The Office of the Public Guardian has published “Deputy Standards”, for these professional deputies and public authority deputies.562 These standards do not have the force of law, but form part of the foundation of the Office’s supervisory function over the work of deputies, which is considerably more intensive than what is found in Ontario.

THE LCO RECOMMENDS:

47: The Government of Ontario conduct further research and consultations towards the goal of enabling community agencies to provide substitute decision-making for day-to-day decisions, such as basic budgeting, bill paying and accessing supports and services, through a program which includes: a) a process for identifying appropriately qualified community agencies; b) lear standards for quality assurance, accountability, avoidance of conflicts of interest, and responding to abuse; c) oversight mechanisms, including reporting and audit requirements; and d) dispute resolution mechanisms.

The LCO believes that the government maintains a responsibility to ensure that Ontarians have access to trustworthy and competent substitute decision- making when they require it.

3. Focusing the Public Guardian and Trustee’s Substitute Decision-Making Role

The LCO believes that the government maintains a responsibility to ensure that Ontarians have access to trustworthy and competent substitute decision-making when they require it. While relatively few Ontarians would identify government as their ideal choice for a substitute decision-maker, preferring that role to be filled through a more personalized relationship, participants in the LCO’s consultations recognized the value of the PGT as an expert, professional and trustworthy decision-maker for those whose needs cannot be appropriately met elsewhere.

There are individuals who, because of their social isolation and low-income do not have access to any other options when it comes to substitute decision-making. There are other individuals who do have family members, but whose family dynamics are so negative or skill levels so low as to put the wellbeing of the individual at risk. There are others whose needs are so challenging that other options are not viable and the expertise and professionalism of the PGT is required to ensure the provision of appropriate substitute decision-making. These individuals, who cannot be adequately served in a for-profit model or by those without considerable expertise in and dedication to addressing the challenging ethical and practical issues that may arise in substitute decision-making, should, in the view of the LCO be the core focus of the PGT’s substitute decision-making activities.

It is in this sense that the LCO believes that a “last resort” role for the PGT should be understood: not solely as a backstop for situations where there are no alternatives at all, but as a provider of expert services for those whose needs cannot be appropriately served by other options. As referenced in Chapter 8, there may also be urgent

THE LCO RECOMMENDS:

48: Subject to the implementation of Recommendations 41, 47 and 48, the Government of Ontario work towards focusing the mandate of the Public Guardian and Trustee on sustainably providing its expert, trustworthy, professional substitute decision-making for those who do not have access to appropriate alternatives.

The creation of other options for those for whom they are appropriate, together with the curtailment of the role of statutory guardianship in Ontario’s system, should reduce some of the pressures currently facing the PGT and enable a renewed and strengthened focus on the needs of those who truly require the assistance of the PGT.

situations where it may be appropriate for the PGT to step in on a temporary basis, while other options are put into place.

A comprehensive review of American public guardianship programs pointed to both the importance and the challenges of this role:

Guardianship is not social work, although it involves important elements of social work. Conversely, guardianship, a product of the courts, is not completely law. Guardianship is an amalgam of many disciplines: law, medicine, social work, and psychology. Most importantly, guardianship deals directly with human beings, society’s most vulnerable human beings. Yet those under the care of the state often are still not afforded basic considerations.

Living the decisional life for these unbefriended people is perhaps the most important and complex state function performed. Guardianship remains shrouded in mystery for most of the public, yet the public guardian performs a highly important state function for the most at-risk population, individuals who deserve no less than excellence from public servants. 563

The LCO recommends that the PGT continue to fill the vital role of SDM of last resort, understood in the sense described above. The creation of other options for those for whom they are appropriate, together with the curtailment of the role of statutory guardianship in Ontario’s system, should reduce some of the pressures currently facing the PGT and enable a renewed and strengthened focus on the needs of those who truly require the assistance of the PGT.

Should statutory guardianship be abolished, as the LCO has recommended in Recommendation 40, to enable this focus for the PGT, it would be important for the legislation to include clear statements of the purpose of the PGT with respect to guardianship, and the criteria under which it should be appointed.

Because of the structural vulnerability of persons for whom an SDM has been appointed, SDMs who are unskilled, uncaring or unethical may have a devastating effect on the lives of persons whom they are appointed to serve.

G. SUMMARY

The role of an SDM is a challenging one, requiring skill, sensitivity, dedication, knowledge of the law and a strong ethical sense. Because of the structural vulnerability of persons for whom an SDM has been appointed, SDMs who are unskilled, uncaring or unethical may have a devastating effect on the lives of persons whom they are appointed to serve.

Ontario’s current system relies heavily on family and friends to undertake this role out of love and duty, with the PGT available as an alternative where necessary. Many are served very well by the current system, but it is also true that changing demographics and family structures are undermining the assumptions on which the current approach is based. There are a number of gaps and shortfalls. The growing need places pressure on the services provided by the PGT, and the PGT, as it is currently constituted, is not well-placed to make personal care decisions for individuals. In some cases, family members, while willing, do not have the necessary skills to carry out this difficult role.

Community organizations may, in some circumstances, be able to provide decision- making on day-to-day, relatively low-risk decisions related to finances and personal care, as part of a more holistic set of services. The LCO also believes that it is worthwhile to work towards developing a licensing and regulatory regime for professional, for-profit substitute decision-makers.

These measures would expand the appropriate options for individuals, reduce the risks of abuse from unregulated options, respond to demographic trends affecting the availability of family members as substitute decision-makers, reduce the “personal care gap”, and more effectively focus the mandate and resources of the Public Guardian and Trustee.