[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] H