[1] In this Paper, we use the term “patient” in the broadest sense, to include any individual for whom treatment is proposed; this may include residents of long-term care homes and clients of other health care organizations. It also includes “person” as that term is used in this Paper. Further, where we refer to “patient”, it is understood that this means either the capable patient, or if the patient has been found incapable to consent to the proposed treatment, his/her SDM as determined under s. 20 of the Health Care Consent Act, 1996, S.O. 1996, c. 2 Sched. A (HCCA).

[2] We should also note that there are statutory exceptions to the requirement to obtain informed consent, such as for time-limited periods where an individual has been found unfit to stand trial in a criminal matter (see Criminal Code, RSC 1985, c C-46  s. 678.58) or where an individual is infected with an agent of a communicable disease that is a virulent disease and has failed to comply with an order of a medical officer of health (see Health Protection and Promotion Act, RSO 1990, c H.7, s. 35).

[3] HCCA, note 1.

[4] The authors wish to thank the Ontario Hospital Association (“OHA”), the Ontario Association of Non-Profit Homes & Services for Seniors (“OANHSS”) and the Ontario Long-Term Care Association (“OLTCA”) for their assistance in facilitating requests of their members for relevant materials.

[5] Starson v. Swayze., 2003 SCC 32, [2003] 1 S.C.R. 722 at 759.

[6] Stephen V. Fram, Final Report of the Advisory Committee on Substitute Decisions Making for Mentally Incapable Persons (Toronto: Guardianship & Advocacy Review Committee, 1987) 42, 45.

[7] Fram, note 6, 42.

[8] Fram, note 6, 44.

[9] Cuthbertson v. Rasouli, 2013 SCC 53 at para. 18 [Rasouli].

[10] Malette v .Shulman (1990), 72 OR (2d) 417, 1990 CarswellOnt 642, (CA) at para. 45.

[11] Fleming v. Reid (1991), 4 O.R. (3d) 74 (C.A.); see also Janet Dunbrack, “Advance care planning: the Glossary project, Final Report”, (Ottawa: Health Canada, August 22, 2006), 20, online: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-proj-glos/2006-proj-gloss-eng.pdf (Last accessed December 11, 2013); Daniel L. Ambrosini, Anne G. Crocker, Eric Latimer, “Preferences for Instructional or Proxy Directives in Mental Health: An Exploratory Mixed Methods Study” 2012 JEMH Vol.  6.

[12] Fram, note 6, 253.

[13] Fram, note 6, 288.

[14] Educating Future Physicians in Palliative and End-of-Life Care, “Facilitating Advance Care Planning: An Interprofessional Education Program” 33-34, online: EFPPEC, http://www.afmc.ca/efppec/docs/pdf_2008_advance_care_planning_curriculum_module_final.pdf

 (Last accessed December 11, 2013) (EFPPEC).

[15] See for example Male v. Hopmans, [1967] 2 O.R. 457 (Ont CA).

[16] Nelitz v. Dyck (2001), 52 OR (3d) 458, 2001 CarswellOnt 27.

[17] Allan v. New Mount Sinai Hospital (1980), 109 D.L.R. (3d) 634, 28 O.R. (2d) 356 (H.C.J.) at paras. 28, 34, rev’d on other grounds (1981), 125 D.L.R. (3d) 276 (Ont. C.A.).

[18] CED, (Ontario 4th) vol 31, title 80 “Hospitals and Health Care”, at §121-122, see also Ellen I. Picard and Gerald B. Robertson, Legal Liability of Doctors and Hospitals in Canada, 4th edition, (Toronto: Thomson Carswell LLP, 2007), 41-54; John J. Morris and Cynthia D. Clarke, Law for Canadian Health Care Administrators, 2nd Edition (Markham, Ontario: LexisNexis, 2011),189-190.

[19] Halsbury’s Laws of Canada, 2013 reissue (LexisNexis Canada Inc., 2013) “Medicine and Health – III Consent to Treatment” (Contributor: Ayanna Ferdinand). Online: Quicklaw, www.lexisnexus.com;  Ciarlariello v. Schacter, [1993] 2 S.C.R. 119.

[20] Timothy Caufield, “Revising Core Principles: Autonomy, Consent, and the Biobanking Challenge” in Jocelyn Downie & Elaine Gibson, eds. Health Law at the Supreme Court of Canada (Canada: LexisNexis, 2007), 169,170.

[21] Malette v. Shulman, note 10, para. 18.

[22] Hopp v .Lepp, [1980] 2 SCR 192 (QL).

[23] Reibl v. Hughes, [1980] 2 SCR 880 (QL).

[24]Lorne E. Rozovsky, The Canadian Law of Consent to Treatment, 3d ed (Canada: LexisNexis, 2003), 161.

[25]Reibl v. Hughes, note 23, 4; Hopp v. Lepp, Note 23, 11-12;Rozovsky, note 24, 161.

[26] Rozovsky, note 24, 162.

[27] Rozovsky, note 24, 161.

[28] Rozovsky, note 24, 162.

[29] Rozovsky, note 24, 163.

[30] Rasouli, note 9, paras. 18-21.

[31] Stell v. Obedkoff, [2000] O.J. No. 4011 (S.C.J.), para. 201.

[32] Young v. Wellesley Hospital, [1994] O.J. No. 1341 (S.C.J.), paras. 122-123; Laurie v. Parham, 2010 MBCA 62, paras. 65-82. See also Flora v. Ontario (Health Insurance Plan, General Manager), 2008 ONCA 538 – discussing denial of OHIP funding.

[33] HCCA, note 1, s. 10.

[34] HCCA, note 1, s. 11(4).

[35] HCCA, note 1,  s. 11(1).

[36] HCCA, note 1, s. 11(2)-(3).

[37] HCCA, note 1, s. 12.

[38] HCCA, note 1, s. 14.

[39] HCCA, note 1, s. 2 “plan of treatment”.

[40] HCCA, note 1, s. 12.

[41] Rasouli, note 9.

[42] HCCA¸ note 1, s. 2(1).

[43] Rasouli, note 9, para. 68.

[44] Rasouli, note 9, para. 70.

[45] HCCA, note 1, ss. 25(3)(e), 26.

[46] HCCA, note 1, s. 29(4).

[47] HCCA, note 1, s. 27.

[48] HCCA, note 1, s. 25(5)-(9).

[49] HCCA, note 1, s. 25(5)-(9).

[50] HCCA, note 1, s. 2(1).

[51] HCCA, note 1, s. 40.

[52] Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, ss. 44(11)(d), 46-47.

[53] HCCA, note 1, s. 47.

[54] HCCA, note 1, s. 2(1).

[55] HCCA, note 1, ss. 2(1) definition of “recipient,” 57-58.

[56] HCCA, note 1, s. 4(2).

[57] HCCA, note 1, s. 4(3).

[58] HCCA, note 1, s. 29.

[59] Starson, note 5, 759.

[60] HCCA, note 1, s. 4(1).

[61] HCCA, note 1, s. 15.

[62] Starson, note 5, at 761-763.

[63] HCCA, note 1, s. 17.

[64] College of Physicians and Surgeons of Ontario, Consent to Medical Treatment, Policy Number: #4-05 (February 2006), 6-7, online: College of Physicians and Surgeons of Ontario, http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/Consent.pdf (Last accessed: October 15, 2013) (Consent Policy).

[65]Mental Health Act, R.S.O. 1990, c. M.7  s. 59 (note also that rights advice is given to the individual for whom a community treatment order is proposed, as well as to the individual’s SDM as applicable).

[66] M.A. v. Benes, 1999 Canlii 3807 (ON CA) para. 23.

[67] Referring to the classical hero Ulysses (Odysseus), who had himself tied to the mast of his ship and his sailors’ ears blocked with wax, so that he could hear the song of the sirens without being drawn closer to shore, where he and his sailors would die. See Homer, The Odyssey, Book XII, Trans. Samuel Barber, online: The Internet Classics Archive, http://classics.mit.edu/Homer/odyssey.12.xii.html (Last accessed, December 10, 2013).

[68] HCCA¸ note 1, s. 32; Substitute Decisions Act, 1992, S.O. 1992, c. 30 s. 50 (SDA).  

[69] SDA. note 68, s. 50.

[70] Starson, note 5, 759-760.

[71] HCCA¸ note 1, s. 32(5)-(7).

[72] HCCA¸ note 1, s. 18(1)-(3).

[73] HCCA¸ note 1, s. 18(4).

[74] HCCA¸ note 1, s. 19.

[75] HCCA¸ note 1, ss. 4(1), 47.1.

[76] HCCA¸ note 1, s. 2(1); Evaluators, O. Reg. 104/96.

[77] HCCA¸ note 1, s. 46.

[78] HCCA¸ note 1, ss. 4(1), 55-69.1.

[79] SDA, note 68, s. 45.

[80] SDA, note 68, s. 49(1), see also s. 66(2.1) and s. 67.

[81] SDA, note 68, s. 49(2).

[82] SDA, note 68, s. 49(2)-(3).

[83] SDA, note 68, s.1(1) “assessor”; Capacity Assessment, O. Reg. 460/05.

[84] SDA, note 68, s. 78(1).

[85] SDA, note 68, s. 78(2).

[86] SDA, note 68, ss. 50(2), 79.

[87] Health Care Consent Act, note 3, s. 20;  Advocacy Centre for the Elderly, “Tip Sheet # 2 Hierarchy of Substitute Decision Makers (SDMs) in the Health Care Consent Act”, online: Advocacy Centre for the Elderly, http://www.acelaw.ca/advance_care_planning_-_publications.php (Last accessed November 5, 2013).

[88] SDA, note 68, ss. 55-68.

[89] SDA, note 68, ss. 46-53, 66-68.

[90] HCCA¸ note 1, ss.  33. 51, 66.

[91] HCCA¸ note 1, ss.20(7)-(8) Definition of Spouse.

[92] HCCA¸ note 1, s .20(9)  Definition of Partner.

[93] HCCA¸ note 1, s.20(10) Definition of Relative.

[94] HCCA¸ note 1, s. 20(6).

[95] HCCA¸ note 1, ss. 20(2)-(3).

[96] HCCA¸ note 1, s. 33(6).

[97] HCCA¸ note 1, s. 33(6)2; D’Arcy Hiltz and Anita Szigeti, A Guide to Consent & Capacity Law in Ontario, 2013 Edition (Markham: LexisNexis, 2013) 185-186.

[98] HCCA¸ note 1, ss. 20(11).

[99] HCCA¸ note 1, s.20(4), Advocacy Centre for the Elderly, Note 90.

[100] HCCA, note 1,  ss. 20(5), 41.

[101] HCCA¸ note 1, s. 58.

[102] Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A, s. 26(6).

[103] HCCA¸ note 1, s. 66.

[104] HCCA¸ note 1, s. 21(1).

[105] HCCA¸ note 1, s. 21(2).

[106] HCCA¸ note 1, s. 22.

[107] M.A. v. Benes, note 66, para. 23.

[108] Rasouli, note 9, paras. 79-88.

[109] HCCA¸ note 1, s. 20(1); SDA, Note 68,   ss. 46-53, 66-68.

[110] SDA, note 68,  s. 46(7).

[111] Re K.M.S., 2007 Canlii 29956 (ON CCB), 11.

[112] SDA, note 68, s. 47(1).

[113] SDA, note 68, ss. 47-49.

[114] SDA, note 68, s. 50.

[115] SDA. note 56, s. 50.

[116] SDA, note 68, s. 55.

[117] SDA, note 68, ss. 58-59.

[118] SDA, Note 68, ss. 66-67.

[119] M.A. v. Benes, note 66, paras. 37-39.

[120] Rasouli, Note 9 , paras. 97-98.

[121] Grover v. Grover (2009), 176 ACWS (3d) 1193, 2009 CarswellOnt 1944 (Ont Sup Ct).

[122] HCCA, note 1, s. 33.

[123] HCCA¸ note 1, s. 34.

[124] HCCA¸ note 1, s. 36.

[125] HCCA¸ note 1, s. 35.

[126] HCCA¸ note 1, s. 37(4)-(7).

[127] HCCA¸ note 1, s. 1(c)(iii).

[128] HCCA¸ note 1, s. 21.

[129] HCCA¸ note 1, s. 5.

[130] Fram, note 6, 288.

[131] Committee Transcripts: Standing Committee on Administration of Justice – December 16, 1991 – Bill 74, Advocacy Act, 1992, and Companion Legislation, at 1700-1710, online: http://www.ontla.on.ca/web/committee-proceedings/committee_transcripts.do?locale=en.

[132] For example, see J.C. (Re), 2010 Canlii 52741 (ON CCB).

[133] Fram, note 6, 251.

[134] Fram, note 6, 48-49, 144, 253-256.

[135] M.A. v. Benes, note 66, para. 44.

[136] HCCA¸ note 1, ss. 25-27.

[137] HCCA¸ note 1, ss. 2(1) and 13.

[138] HCCA¸ note 1, s. 11(3).

[139] Scardoni v. Hawryluck, (2004) 69 OR (3d) 700, (Ont Sup Ct) (Scardoni).

[140] Scardoni, note 139, para. 59.

[141] Rasouli, note 9, at para. 105.

[142] M.B. (Re), 2008 Canlii 3954 (ON CCB) 21-22. see also K.M.S. (Re), 2007 Canlii 29956 (ON CCB) where the CCB held that, even if a statement in a power of attorney was not a wish applicable in the circumstances, it constitute the patient’s value and beliefs about the dying process.

[143] M.F. (Re), 2003 Canlii 14908 (ON CCB) 7-8.

[144] M.F. (Re), note 146, 9.

[145] M.F. (Re), note 146, 9, see also See I.A. (Re), 2004 Canlii 29268 (ON CCB) 15-16.

[146] S.S. (Re), 2012 Canlii 85612 (ON CCB) 14.

[147] S.S. (Re), Note 149, at pp. 13-14, 18; also see G.S. (Re) 2012 Canlii 42098 (ON CCB);

[148] M. (Re), 2009 CanLII 33714 (ON CCB) 5-11.

[149] Barbulov v. Cirone, 2009 Canlii 15889 (ON SC) paras. 45-48, 61, 95; see also Friedberg et al. v. Korn, 2013 ONSC 960.

[150] Rasouli, note 9, para. 96.

[151] Health Care (Consent) and Care Facility (Admission) Act,  RSBC 1996, c 181, s. 3.

[152] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 4.

[153] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 5.

[154] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 6, “advance directive”.

[155] Health Care (Consent) and Care Facility (Admission) Act, note 151, s 1.

[156] Representation Agreement Act, RSBC 1996, c 405.

[157] Representation Agreement Act, note 156, ss. 2, 7-8.

[158] Representation Agreement Act, note 156,  ss. 1 “health care”, 7-8; There are limitations on the treatments to which a representative can consent to, see Representation Agreement Act, note 156, s. 9(2).

[159] Representation Agreement Act, note 159, ss. 12, 20; We have been advised by a British Columbia lawyer that the requirement for a monitor for financial matters flows from the fact that the test for capacity to appoint a representative is lower than the threshold for capacity to create an enduring power of attorney in British Columbia. This resulted in the extra-protective measures of a monitor for representation agreements addressing financial matters.

[160] Representation Agreement Act, note 156, s. 16.

[161] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 19.3.

[162] Representation Agreement Act, note 156, s. 16.

[163] Representation Agreement Act, note 156, s. 16.

[164] Representation Agreement Act, note 156, s. 16(7).

[165] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 19.7.

[166] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 9(1.1) – however, there are some treatments for which consent by advance directive is not possible.

[167] Health Care (Consent) and Care Facility (Admission) Act, note 151, ss. 9, 19.7 – 19.8.

[168] Health Care (Consent) and Care Facility (Admission) Act, note 151, ss. 19.8(1).

[169] Health Care (Consent) and Care Facility (Admission) Act, note 151, ss. 19.8(2).

[170] Health Care (Consent) and Care Facility (Admission) Act, note 151, ss. 19.8(3).

[171] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 1 “advance directive”.

[172] Health Care (Consent) and Care Facility (Admission) Act, note 151, s.19; Representation Agreement Act, note 156, s. 16.

[173] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 16.

[174] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 19; Please note that there are limitations on the treatments to which a temporary substitute decision maker can consent to, see Health Care Consent Regulation, BC Reg 20/2000, s. 5.

[175] Health Care (Consent) and Care Facility (Admission) Act, note 151, s. 33.4. 

[176] Representation Agreement Act, note 156, ss. 30-34.

[177] Personal Directives Act, RSA 2000, c P-6.

[178] Personal Directives Act. note 177, s 1(l).

[179] Personal Directives Act. note 177, ss 1(k), 5(1).

[180] Personal Directives Act. note 177, s 14(1).

[181] Adult Guardianship and Trustee Act,  SA 2008, c A-4.2.

[182] Adult Guardianship and Trustee Act, note 181, ss. 3-10.

[183] Adult Guardianship and Trustee Act, note 181, s. 6.

[184] Personal Directives Act. note 177, s 14(2).

[185] Personal Directives Act. note 177, s 14(3); Interestingly, agents may also be required to make decisions in accordance with the best interests requirement under the Alberta Mental Health Act,  RSA 2000, c M-13, s. 28, leaving open the possibility of conflicting decision-making obligations.

[186] Personal Directives Act. note 177, s 19(1)(a).

[187] Personal Directives Act. note 177, s.  23.

[188] Personal Directives Act. note 177, s 19(1)(b).

[189] Personal Directives Act. note 177, s 19(2).

[190] Personal Directives Act. note 177, s. 14.

[191] Adult Guardianship and Trustee Act,  note 181.

[192] Adult Guardianship and Trustee Act, note 181, ss. 87-88.

[193] Adult Guardianship and Trustee Act, note 181, ss. 1 “nearest relative” , 89.

[194] Adult Guardianship and Trustee Act, note 181, s. 92

[195] Adult Guardianship and