3. Jurisprudence - Lecture 3 - Notes
Emergency Consent in Emergencies
An informed consent exception exists in emergencies when a patient is incapable or when delaying treatment would cause suffering or serious bodily harm.
Two emergency scenarios mentioned:
Patient is incapable and delaying treatment would cause suffering or serious bodily harm.
Language or communication barrier exists (language disability), despite efforts to accommodate, and delaying treatment would cause suffering or serious bodily harm.
In both scenarios, there is suffering and/or serious bodily harm, which creates the emergency exception to consent.
Even in emergencies, practitioners must attempt to obtain consent:
Find a substitute decision maker in the first scenario.
Find ways to communicate (including translation or language services) in the second scenario.
Emergencies are usually rare for practitioners, but it’s possible to encounter emergencies in non-acute settings (e.g., someone with acupuncture who experiences a medical emergency while waiting for surgery).
In clinic settings, you should have:
CPR and first aid training
Clear protocols and procedures
A plan for how front-d desk staff or the clinician will approach emergencies
The key criterion remains: any delay in treatment would cause suffering or serious bodily harm.
Even when consent is not fully required due to emergency, you should still attempt to communicate with the patient if conscious and involve them or their decision maker as soon as feasible.
Consent Scenarios
Scenario 1: Defibrillator use without substitute consent (heart attack)
Practitioner Y treats Paula who suddenly collapses from a heart attack.
Y has a defibrillator (AED) in the office.
Y administers defibrillation without obtaining substitute decision maker consent because this is a medical emergency.
Paula is unconscious; her heart is not necessarily beating normally.
Communication with bystanders: explain the situation (e.g., "Paula is having a heart attack; we’re following CPR protocol").
This is consistent with emergency consent rules; you are not performing acupuncture, you’re providing life-saving interventions.
Important: document the events and maintain clear communication with staff and family as appropriate.
Scenario 2: DNR (Do Not Resuscitate) and preexisting refusals
Paul has terminal cancer and a wallet card indicating a DNR.
Paul collapses from a sudden cardiac event.
Practitioner X has a defibrillator in the office but cannot act against the preexisting DNR.
If a DNR exists and is documented in the chart, you are not to perform resuscitation or life-saving measures contrary to the DNR.
If X did not know about the DNR, he could have performed life-saving measures; with knowledge of the DNR, he must respect the patient's previously stated wishes.
The chart must clearly document the DNR status.
If the patient’s wishes are unknown to the practitioner, there may be liability or different regulatory considerations; always verify and document.
Intake forms and consent conversations
Intake forms typically do not exhaustively capture every potential emergency consent scenario.
It’s important to discuss and document patient preferences (where relevant) and ensure you have access to their medical history, including any advance directives.
In hospice or terminally ill patients, consider including relevant consent discussions and documents in the chart.
If you are unaware of a patient’s wishes, you may proceed with life-saving measures in an emergency, but you should consult regulators and institutional protocols.
Informed Consent: Core Principles
Informed consent gives patients the right to control what happens to their bodies and health.
Consent must be obtained for each step, or via preset consent for commonly used procedures, while ensuring it remains specific and context-appropriate.
Informed consent requires, at minimum, that patients are informed and understand:
The nature of the assessment or treatment
Who will perform it
The reasons for the treatment
The risks and potential side effects
The alternatives to the proposed treatment
The consequences of not having the treatment or delaying it
Any questions or clarifications
Consent must be voluntary; you cannot coerce or pressure a patient to sign.
Informed consent is not just a signature; it is an ongoing process to ensure understanding and voluntariness.
A conceptual formulation for informed consent can be summarized as:
For acupuncturists and others who may hold multiple professional hats, it is important to clarify scope and ensure consent is specific to the activity being performed.
What to include in consent discussions
Nature of the assessment or treatment
Identity of the person who will perform it
Reasons for the treatment
Associated risks and potential side effects
Available alternatives
What happens if you do not proceed, or if you wait
Opportunity for questions and clarification
Ensure the patient’s decision is voluntary
Boundaries and Sexual Abuse
Boundaries in practice
Maintain professional boundaries at all times; avoid dual relationships that could compromise objectivity.
Boundaries help protect both patient and practitioner and prevent misunderstandings about the nature of the relationship.
Clear boundaries include separating professional duties from personal life, avoiding overly familiar or intimate interactions, and sticking to clinic hours and professional conduct.
Dual relationships (e.g., treating a friend or family member) should be avoided whenever possible; if unavoidable, set strict boundaries and consider referral to another practitioner.
Physical boundaries: be explicit about what you will and won’t touch, explain before touch, and obtain consent for any clinical touch.
If a boundary is crossed or a patient expresses romantic interest, stop the interaction and consider transferring care to another practitioner.
Boundaries with gifts, self-disclosure, and bartering
Gifts: small tokens are common, but gifts can create expectations or conflicts of interest. If unsure, refuse or redirect to a charitable donation instead. You may set a policy (e.g., no personal gifts or use them for a clinic fundraiser).
Gift cards and barter: any form of compensation or mutual exchange that benefits the practitioner can create a conflict of interest; avoid gifts that are tied to ongoing treatment or referrals. Bartering (e.g., exchange of services) should be carefully considered and typically discouraged.
Self-disclosure: minimal and professional; share only information that helps the patient and does not shift the focus to the practitioner’s life. Avoid divulging personal issues that could blur boundaries.
The practitioner’s stated personal opinions (politics, religion, etc.) should be kept out of care conversations to prevent misinterpretation or discomfort.
Boundaries with dual relationships and colleagues
Dual relationships with colleagues or staff (e.g., treating a coworker, or discussing sexual topics in front of staff or other patients) should be avoided to prevent conflicts of interest and misinterpretation.
If a patient or colleague crosses a boundary, address it directly and professionally, and consider transferring care if needed.
Relationships with patients who are or become partners (spouse, fiancé, significant other) are prohibited while the professional relationship exists; if such a relationship develops, transfer the patient's care and observe a cooling-off period before considering a future relationship.
Boundaries with friends and family
Best practice is not to treat friends or family members due to the risk of compromised objectivity and boundary confusion.
If you do treat a friend or family member, seek a second opinion or refer to another practitioner when possible; otherwise, maintain strict boundaries and document interactions.
Spousal or intimate partner relationships are strictly prohibited in most regulatory frameworks; never treat a spouse or sexual partner, and transfer care to another practitioner.
Boundaries in practice: cultural and social considerations
Cultural norms around gifts or favors require sensitivity, but professionals should remain within policy guidelines.
Small tokens (e.g., a card) may be acceptable if they don’t create reciprocity or expectations.
Routine office hours and customary practices should be maintained to avoid misinterpretation about availability or closeness.
Recognizing and preventing sexual abuse
Sexual abuse includes: any sexual contact with a patient, sexual behavior or remarks by the practitioner toward the patient, or sexual acts involving touch in non-clinical contexts.
Examples of prohibited conduct include touching in a sexual manner, discussing sexual history inappropriately, or making sexual jokes or remarks in clinical settings.
Treating a spouse or intimate partner is generally prohibited, and any such relationship could be deemed sexual abuse; if a patient is a spouse, transfer care and document the process.
If sexual abuse occurs, practitioners must stop the behavior immediately and may need to report to the regulatory college and/or police, depending on the jurisdiction and severity.
The college enforces a zero-tolerance policy for sexual abuse, with serious consequences including possible loss of licensure.
Documentation is crucial: record all incidents, communications, and steps taken, including any warnings, transfers, or reports.
There are formal processes for reporting sexual abuse, including possible anonymous reporting and disciplinary investigations.
Practical tips to prevent sexual abuse and misconduct
Do not initiate or engage in sexual conversations or jokes with patients.
Do not treat anyone with whom you have or later develop a sexual relationship.
Obtain explicit consent for any touching beyond strictly clinical necessity; use witnesses when appropriate.
Do not expose patients beyond what is clinically necessary; explain all steps when disrobing or exposing areas for treatment.
If a patient makes a sexual advance, stop it firmly and clearly; if necessary, terminate treatment and refer to another practitioner.
If you suspect abuse, document and escalate according to your regulatory body’s procedures and report to the appropriate authorities if required.
Maintain objective, non-sexual communication and avoid disclosures that could blur professional boundaries.
When in doubt, err on the side of caution and seek guidance from supervisors, peers, or your regulatory college.
Documentation, Reporting, and Duty to Report
The regulatory body has a duty to investigate allegations of sexual abuse.
Mandatory reporting requirements exist for suspected abuse, with procedures to report to the college or appropriate authorities.
Some aspects of reporting can be anonymous, but may still require follow-up information.
Documentation should be detailed and factual: what happened, who was involved, what was said or done, and what actions were taken (e.g., transfer of care, investigation, police report).
If a complaint is made by a patient, you should cooperate with the college and any investigations, and ensure patient confidentiality within legal limits.
Interprofessional Collaboration (IPC)
IPC involves coordinating care with other practitioners (e.g., massage therapists, physiotherapists, chiropractors, naturopaths, medical doctors) to provide comprehensive patient care.
Ensure consent to share personal health information to facilitate collaboration, per privacy laws (e.g., PHIPA or equivalent).
Share plans and updates with other providers to prevent treatment conflicts, adverse interactions, and missed medications.
Always check for contraindications when combining herbs/supplements with other medications.
Even when collaborating, maintain patient consent for information sharing and ensure the patient understands the purpose of sharing information.
In cases where a practitioner discusses a patient’s medication or care with another provider, do not violate your scope of practice; avoid counseling beyond your professional boundaries; defer to the patient’s primary prescriber when appropriate.
IPC in practice: a scenario
Paula’s family doctor calls to inquire whether Paula’s current treatment plan (from X) might be interacting with her prescribed medications.
The correct approach:
Obtain consent to discuss Paula’s information with the family doctor.
Acknowledge that discussing medications or altering prescriptions is often outside your scope; encourage coordination with Paula’s physician.
Communicate only within your scope of practice and refer for changes to the physician as needed.
Professional Boundaries: Quick Reference
Never engage in romantic or sexual relationships with patients.
Do not treat relatives or close friends; if unavoidable, transfer care and set strict boundaries.
Avoid dual relationships that could bias judgments or blur lines between professional and personal life.
Keep gifts/artifacts to a minimum and avoid those that could create a sense of obligation.
Avoid discussing sensitive topics (politics, religion, sexuality) in a way that could make patients uncomfortable or misinterpret your intentions.
If a boundary is crossed, stop the behavior, reassess the relationship, and consider referral to another practitioner.
Practice Considerations and Exam-Relevant Points
The core purpose of consent is patient autonomy and safety; emergencies can override consent but not the obligation to attempt consent where feasible.
In emergencies, you may perform life-saving measures without consent if delaying would cause harm; document what you did and why.
DNR orders must be respected; always verify and document before acting.
Informed consent should be specific and not overly broad; use clearly defined questions and explanations.
Boundaries protect patient safety and practitioner integrity; dual relationships and inappropriate self-disclosure are common sources of boundary violations.
Gifts can complicate care; handle with caution and consider alternatives like charitable donations.
Sexual abuse in a clinical setting includes sexual contact, sexual remarks, or inappropriate touching; a practitioner must intervene and may face disciplinary action.
Duty to report suspected abuse is mandatory and serious; reporting may be anonymous but must be pursued.
Interprofessional collaboration enhances patient care; ensure consent to share information and maintain scope of practice.
Always document interactions, boundary issues, and any safety concerns; documentation protects both patient and practitioner.
Key Terms and Concepts
Informed consent
Emergency exception to consent
Substitute decision maker
DNR (Do Not Resuscitate)
Dual relationships
Boundaries
Self-disclosure
Gifts and bartering
Sexual abuse (RHPA definition and scope)
Sexual misconduct (non-patient settings)
Duty to report / mandatory reporting
Interprofessional collaboration (IPC)
Personal health information privacy (PHIPA or equivalent)
Scope of practice
Cooling-off period (when a practitioner may pursue a relationship after treating a former patient)
Charting and documentation practices