The Canadian Health Care System Flashcards

Question

Who governs physician certification

Answer 1

physician certification is governed nationally, while the medical profession in Canada self-regulates under the authority of provincial legislation

Answer 2

Provides leadership to doctors and advocates for access to high quality care in Canada Represents physician and population concerns at the national level Membership is voluntary

Answer 3

Negotiates fee and benefit schedules with provincial governments Represents the economic and professional interests of doctors Membership is voluntary

Answer 4

Physician-run organization that protects the integrity of member physicians Provides legal defence against allegations of malpractice or negligence Provides risk management and educational programs Membership is voluntary

Answer 5

Upholds economic and professional interests of residents across Canada Facilitates discussion amongst PHOs regarding policy and advocacy items

Answer 6

Medcal students are represented at their universities by student bodies, which collectively form the CFMS or FMÉQ FMÉQ membership includes that of francophone medical schools

Answer 7

* the doctor-patient relationship is formed on trust, which is recognized in the concept of fiduciary duty/ responsibility of physician towards patient * a fiduciary duty is a legal duty to act solely in another party’s interest; one may not profit from the relationship with principals unless he/she has the principal’s express consent

Answer 8

• ethics addresses: 1. principles and values that help define what is morally right and wrong 2. rights, duties and obligations of individuals and groups

Answer 9

Recognizes an individual’s right and ability to decide for himself/herself according to his/her beliefs and values Not applicable in situations where informed consent and choice are not possible or may not be appropriate

Answer 10

Patient-based ‘best interests’ standard that combines doing good, avoiding harm, taking into account the patient’s values, beliefs, and preferences, so far as these are known Autonomy should be integrated with the physician’s conception of a patient’s medically-defined best interests Aim is to minimize harmful outcomes and maximize beneficial ones Paramount in situations where consent/choice is not possible or may not be appropriate

Answer 11

Obligation to avoid causing harm; primum non nocere (“First, do no harm”) Limit condition of the Beneficence principle

Answer 12

Fair distribution of benefits and harms within a community, regardless of geography or privilege Concept of fairness: Is the patient receiving what he/she deserves – his/her fair share? Is he/she treated the same as equally situated patients? How does one set of treatment decisions impact others? Basic human rights, such as freedom from persecution and the right to have one’s interests considered and respected

Answer 13

Autonomy: the right that patients have to make decisions according to their beliefs and preferences Competence: the ability or capacity to make a specific decision for oneself

Answer 14

• the Code of Ethics is: ■ prepared by physicians for physicians and applies to physicians, residents, and medical students ■ based on the fundamental ethical principles of medicine ■ sources include the Hippocratic Oath, developments in human rights, recent bioethical discussion ■ CMA policy statements address specific ethical issues not mentioned by the code (e.g. abortion, transplantation, and euthanasia) The CMA Code of Ethics is a quasi-legal standard for physicians; if the law sets a minimal moral standard for doctors, the Code augments these standards

Answer 15

■ control of their own information ■ the expectation that information concerning them will receive proper protection from unauthorized access by others

Answer 16

• physicians should seek advice from their local health authority or the CMPA before disclosing HIV status of a patient to someone else ■ many jurisdictions make mandatory not only the reporting of serious communicable diseases (e.g. HIV), but also the reporting of those who harbour the agent of the communicable disease ■ physicians failing to abide by such regulations could be subject to professional or civil actions

Answer 17

• unlike the solicitor-client privilege, there is no ‘physician-patient privilege’ by which a physician, even a psychiatrist, can promise the patient absolute confidentiality

Answer 18

• legal duty to maintain patient confidentiality is imposed by provincial health information legislation and precedent-setting cases in the common law

Answer 19

“Disclose your patients’ personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves. In such cases take all reasonable steps to inform the patients that the usual requirements for confidentiality will be breached” * Protect the health information of your patients * Provide information reasonable in the circumstances to patients about the reasons for the collection, use, and disclosure of their health information * Be aware of your patients’ rights with respect to the collection, use, disclosure, and access to their health information; ensure that such information is recorded accurately

Answer 20

1. suspected child abuse or neglect – report to local child welfare authorities (e.g. Children’s Aid Society) 2. fitness to drive a vehicle or fly an airplane – report to provincial Ministry of Transportation (see Geriatric Medicine, GM11) 3. communicable diseases – report to local public health authority (see Population Health and Epidemiology, PH24) 4. improper conduct of other physicians or health professionals – report to College or regulatory body of the health professional (sexual impropriety by physicians is required reporting in some provinces) 5. vital statistics must be reported; reporting varies by province (e.g. in Ontario, births are required to be reported within 30 days to Office of Registrar General or local municipality; death certificates must be completed by a MD then forwarded to municipal authorities) 6. reporting to coroners (see Physician Responsibilities Regarding Death, ELOM14) 7. Duty to Protect/Warn • physicians who fail to report in these situations are subject to prosecution and penalty, and may be liable if a third party has been harmed

Answer 21

* the physician has a duty to protect the public from a known dangerous patient; this may involve taking appropriate clinical action (e.g. involuntary detainment of violent patients for clinical assessment), informing the police, or warning the potential victim(s) if a patient expresses an intent to harm first established by a Supreme Court of California decision in 1976 (Tarasoff v. Regents of the University of California); supported by Canadian courts * obliged by the CMA Code of Ethics and recognized by some provincial/territorial regulatory authorities * concerns of breaching confidentiality should not prevent the MD from exercising the duty to protect; however, the disclosed information should not exceed that required to protect others * applies in a situation where: 1. there is a clear risk to identifiable person(s); 2. there is a risk of serious bodily harm or death; and 3. the danger is imminent (i.e. more likely to occur than not) * there should be a duty to inform when a patient reveals that he/she intends to do serious harm to another person(s) and it is more likely than not that the threat will be carried out. * where a threat is directed at a person or group and there is a specific plan that is concrete and capable of commission and the method for carrying it out is available to the threatener the physician should immediately notify the police and, in appropriate circumstances, the potential victim The report should include the threat, the situation, the physician’s opinion, and the information upon which it is based.

Answer 22

disclosure of health records can be compelled by a court order, warrant, or sub poena

Answer 23

privacy of health information is protected by professional codes of ethics, provincial and federal legislation, the Canadian Charter of Rights and Freedoms, and the physician’s fiduciary duty

Answer 24

the feder l government created the PIPEDA in 2000 which established principles for the collection, use, and disclosure of information that is part of commercial activity (e.g. physician practices, pharmacies, private labs) • PIPEDA has been superseded by provincial legislation in many provinces, such as the Ontario Personal Health Information Protection Act, which applies more specifically to health information

Answer 25

• inform patients of information-handling practices through various means (e.g. posting notices, brochures and pamphlets, and/or through discussions with patients) • obtain the patient’s expressed consent to disclose information to third parties ■ under Ontario privacy legislation, the patient’s expressed consent need not be obtained to share information between health care team members involved in the “circle of care.” However, the patient may withdraw consent for this sharing of information and may put parts of the chart in a “lock box” * provide the patient with access to their entire medical record; exceptions include instances where there is potential for serious harm to the patient or a third party * provide secure storage of information and implement measures to limit access to patient records * ensure proper destruction of information that is no longer necessary * regarding taking pictures or videos of patients, findings, or procedures, in addition to patient consent and privacy laws, trespassing laws apply in some provinces * CPSO published policy is designed to help Ontario physicians understand legal and professional obligations set out under the Regulated Health Professions Act, 1991, the Medicine Act, 1991, and the Personal Health Information Protection Act, 2004. This includes regulations regarding express or implied consent, incapacity, lock boxes, disclosure under exceptional circumstances, mandatory reporting, ministry audits, subpoenas, court orders and police, as well as electronic records and voice messaging communications: http://www.cpso.on.ca/Policies-Publications/Policy/Confidentiality-of-PersonalHealth-Information * it is the physician’s responsibility to ensure appropriate security provisions with respect to electronic records and communications

Answer 26

The term “lock boxes” applies to situations where the patient has expressly restricted his or her physician from disclosing specific aspects of their health information to others, even those involved in the patient’s circle of care. Note that PHIPA provisions denote that patients may not prevent physicians from disclosing personal health information permitted/required by the law.

Answer 27

autonomous authorization of a medical intervention by a patient

Answer 28

where a patient cannot make an autonomous decision (i.e. incapable), it is the duty of the SDM (or the physician in an emergency) to act on the patient’s known prior wishes or, failing that, to act in the patient’s best interests there is a duty to discover, if possible, what the patient would have wanted when capable central to determining best interests is understanding the patient’s values, beliefs, and cultural or religious background * more recently expressed wishes take priority over remote ones * patient wishes may be verbal o written * patients found incapable to make a specific decision should still be involved in that decision as much as possible

Answer 29

usually the principle of respect for patient autonomy overrides the principle of beneficence

Answer 30

agreement or disagreement with medical advice does not determine findings of capacity/incapacity • however, patients opting for care that puts them at risk of serious harm that most people would want to avoid should have their capacity carefully assessed

Answer 31

1. Voluntary ■ consent must be given free of coercion or pressure (eg. from parents or other family members who might exert ‘undue influence’) ■ the physician must not deliberately mislead the patient about the proposed treatment 2 Capable ■ the patient must be able to understand and appreciate the nature and effect of the proposed treatment 3. Specific ■ the consent provided is specific to the procedure being proposed and to the provider who will carry out the procedure (e.g. the patient must be informed if students will be involved in providing the treatment) 4. Informed ■ sufficient information and time must be provided to allow the patient to make choices in accordance with his/her wishes, including: ◆ the nature of the treatment or investigation proposed and its expected effects ◆ all significant risks and special or unusual risks ◆ alternative treatments or investigations and their anticipated effects and significant risks ◆ the consequences of declining treatment ◆ risks that are common sense need not be disclosed (i.e. bruising after venipuncture) ◆ answers to any questions the patient may have ■ the reasonable person test – the physician must provide all information that would be needed “by a reasonable person in the patient’s position” to be able to make a decision ■ disclose common adverse events (>1/200 chance of occurrence) and serious risks (e.g. death), even if remote ■ it is the physician’s responsibility to make reasonable attempts to ensure that the patient understands the information ■ physicians should not withhold information about a legitimate therapeutic option based on personal conscience (e.g. not discussing the option of emergency contraception)

Answer 32

* Patient is experiencing extreme suffering | * Patient is at risk of sustaining serious bodily harm if treatment is not administered promptly

Answer 33

The Supreme Court of Canada expects physicians to disclose the risks that a “reasonable” person would want to know. In practice, this means disclosing minor risks that are common as well as serious risks that happen infrequently, especially those risks that are particularly relevant to a particular patient (e.g. hearing loss for a musician)

Answer 34

• consent of the patient must be obtained before any medical intervention is provided; consent can be verbal or written, although written is usually preferred ■ a signed consent form is only evidence of consent – it does not replace the process for obtaining valid consent ■ most important component is what the patient understands and appreciates, not what the signed consent form states ■ implied (e.g. a patient holding out their arm for an immunization) or expressed * consent is an ongoing process and can be withdrawn or changed after it is given, unless stopping a procedure would put the patient at risk of serious harm * HCCA of Ontario (1996) covers consent to treatment, admission to a facility, and personal assistance services (e.g. home care)

Answer 35

1. Emergencies ■ treatment can be provided without consent where a patient is experiencing severe suffering, or where a delay in treatment would lead to serious harm or death and consent cannot be obtained from the patient or their SDM ■ emergency treatment should not violate a prior expressed wish of the patient (e.g. a signed Jehovah’s Witness card) ■ if patient is incapable, MD must document reasons for incapacity and why situation is emergent ■ patients have a right to challenge a finding of incapacity as it removes their decision-making ability ■ if a SDM is not available, MD can treat without consent until the SDM is available or the situation is no longer emergent 2. Legislation ■ Mental Health legislation allows for: ◆ the detention of patients without their consent ◆ psychiatric outpatients may be required to adhere to a care plan in accordance with Community Treatment Orders (see Psychiatry, PS51) ◆ Public Health legislation allows medical officers of health to detain, examine, and treat patients without their consent (e.g. a patient with TB refusing to take medication) to prevent transmission of communicable diseases 3. Special Situations ■ public health emergencies (e.g. an epidemic or communicable disease treatment) ■ warrant for information by police

Answer 36

* treatment without consent is battery (an offense in tort), even if the treatment is life-saving (excluding situations outlined in exceptions section above) * treatment of a patient on the basis of poorly informed consent may constitute negligence, also an offense in tort * the onus of proof that valid consent was not obtained rests with the plaintiff (usually the patient)

Answer 37

• capacity is the ability to: ■ understand information relevant to a treatment decision ■ appreciate the reasonably foreseeable consequences of a decision or lack of a decision * capacity is specific for each decision (e.g. a person may be capable to consent to having a chest x-ray, but not for a bronchoscopy) * capacity can change over time (e.g. temporary incapacity secondary to delirium) * most Canadian jurisdictions distinguish capacity to make healthcare decisions from capacity to make financial decisions; a patient may be deemed capable of one, but not the other * a person is presumed capable unless there is good evidence to the contrary * capable patients are entitled to make their own decisions * capable patients can refuse treatment even if it leads to serious harm or death; however, decisions that put patients at risk of serious harm or death require careful scrutiny

Answer 38

Capacity is an essential component of valid consent, and obtaining valid consent is a policy of the CMA and other professional bodies

Answer 39

Test for understanding: can the patient recite what you have disclosed? Test for appreciation: are his/her beliefs responsive to evidence? • capacity assessments must be conducted by a physician and, if appropriate, in consultation with other healthcare professionals (e.g. another physician, a mental health nurse) • clinical capacity assessment may include: ■ specific capacity assessment (i.e. capacity specific to the decision at hand): 1 effective disclosure of information and evaluation of patient’s reason for decision 2. understanding of: – his/her condition – the nature of the proposed treament – alternatives to the treatment – the consequences of accepting and rejecting the treatment – the risks and benefits of the various options 3. for the appreciation needed for decision making capacity, a person must – acknowledge the condition that affects him/herself – be able to assess how the various options would affect him or her – be able to reach a decision and adhere to it, and make a choice, not based primarily upon delusional belief * general impressions * input from psychiatrists, neurologists, etc. * employ “Aid to Capacity Evaluation” * a decision of incapacity may warrant further assessment by psychiatrist(s), legal review boards (e.g. in Ontario, the Consent and Capacity Review Board), or the courts * judicial review is open to patients if found incapable

Answer 40

• obtain informed consent from SDM • an incapable patient can only be detained against his/her will to receive treatment if he/she meets criteria for certification under the Mental Health Act (see Psychiatry, PS50); in such a situation: ■ document assessment in chart ■ notify patient of assessment using appropriate Mental Health Form(s) (Form 42 in Ontario) ■ notify Rights Advisor

Answer 41

* Ability to understand the medical problem * Ability to understand the proposed treatment * Ability to understand the alternatives (if any) to the proposed treatment * Ability to understand the option of refusing treatment or of it being withheld or withdrawn * Ability to appreciate the reasonably foreseeable consequences of accepting the proposed treatment * Ability to appreciate the reasonably foreseeable consequences of refusing the proposed treatment * Ability to make a decision that is not substantially based on delusions or depression

Answer 42

• SDMs must follow the following principles when giving informed consent: ■ act in accordance with wishes previously expressed by the patient while capable ■ if wshes unknown, act in the patient’s best interest, aking the following into account: 1. values and beliefs held by the patient while capable 2. whether well-being is likely to improve with vs. without treatment 3. whether the expected benefit outweighs the risk of harm 4. whether a less intrusive treatment would be as beneficial as the one proposed • the final decision of the SDM may and should be challenged by the MD if the MD believes the SDM is not abiding by the above principles

Answer 43

* Legally appointed guardian * Appointed attorney for personal care, if a power of attorney confers authority for treatment consent (see Powers of Attorney) * Representative appointed by the Consent and Capacity Board * Spouse or partner * Child (age 16 or older) or parent (unless the parent has only a right of access) * Parent with only a right of access * Sibling * Other relative(s) * Public guardian and trustee

Answer 44

* allow patients to exert control over his/her care once they are no longer capable * the patient sets out his/her decisions about future health care, including who he/she would allow to make treatment decisions on his/her behalf and what types of interventions he/she would want * takes effect once the patient is incapable with respect to treatment decisions * in Ontario, a person can appoint a power of attorney for personal care to carry out his/her advance directives * patients should be encouraged to review these documents with their family and physicians and to reevaluate them often to ensure they are current with their wishes

Answer 45

There is no age of consent in Ontario Capacity is assessed on an individual basis

Answer 46

* Testamentary (ability to make a will) * Fitness (ability to stand trial) • Financial (ability to manage property – Form 21 of the Mental Health Act) * Personal (ability to care for oneself on a daily basis)

Answer 47

■ a legal document in which one person gives another the authority to make personal care decisions (health care, nutrition, shelter, clothing, hygiene, and safety) on their behalf if they become mentally incapable.

Answer 48

■ someone who is appointed by the Court to make decisions on behalf of an incapable person in some or all areas of personal care, in the absence of a POA for personal care

Answer 49

■ legal document in which a person gives another the legal authority to make decisions about their finances if they become unable to make those decisions

Answer 50

■ someone who is appointed by the Public Guardian and Trustee or the Courts to look after an incapable person’s property or finances

Answer 51

■ acts as a SDM of last resort on behalf of mentally incapable people who do not have another individual to act on their behalf

Answer 52

■ no age of consent in all provinces and territories except Québec; consent depends on patient’s decision-making capacity ■ Québec has a specific age of consent, but common law and case law deem underage legal minors capable, allowing these individuals to make their own choices ■ infants and children are assumed to lack mature decision-making capacity for consent but they should still be involved (i.e. be provided with information appropriate to their comprehension level) ■ adolescents are usually treated as adults ■ preferably, assent should still be obtained from patient, even if not capable of giving consent ■ in the event that the physician believes the SDM is not acting in the child’s best interests, an appeal must be made to the local child welfare authorities ■ under normal circumstances, parents have right of access to the child’s medical record

Answer 53

Errors of care are compatible with non-negligent care if they are ones that a reasonably cautious and skilled MD could make (i.e. mistakes can be made due to ‘honest error’)

Answer 54

* the doctor-patient relationship is formed on trust, which is recognized in the concept of fiduciary duty/ responsibility of physician towards patient * negligence or malpractice is a form of failure on the part of the physician in fulfilling his/her fiduciary duty in providing appropriate care and leading to harm of the patient (and/or abuse of patient’s trust)

Answer 55

* physicians are legally liable to their patients for causing harm (tort) through a failure to meet the standard of care applicable under the circumstances * standard/duty of care is defined as one that would reasonably be expected under similar circumstances of an ordinary, prudent physician of the same training, experience, specialization, and standing * liability arises from physician’s common law duty of care to his/her patients in the doctor/patient relationship (or, in Québec, from the Civil Code provisions regarding general civil liability) * action(s) in negligence (or civil liability) against a physician must be launched by a patient within a specific prescribed period required by the respective province in which the actions occurred

Answer 56

1. A duty of care owed to the patient (i.e. doctor/patient relationship must be established) 2. A breach of the standard of care 3. Some harm or injury to the patient 4. The harm or injury must have been caused by the breach of the duty of care

Answer 57

* helps to promote and maintain a trusting physician-patient relationship * patients have a right to be told important informaton that physicians have regarding their care * enables patients to make informed decisions about health care and their lives

Answer 58

• required for valid patient consent (see Consent and Capacity, ELOM7) ■ goal is to disclose information that a reasonable person in the patient’s position would need in order to make an informed decision (“standard of disclosure”) * withholding information can be a breach of fiduciary duty and duty of care * obtaining consent on the basis of misleading information can be seen as negligent

Answer 59

* most patients want to know what is wrong with them * although many patients want to protect family members from bad news, they themselves would want to be informed in the same situation * truth-telling improves adherence and health outcomes * informed patients are more satisfied with their care * negative consequences of truth-telling can include decreased emotional well-being, anxiety, worry, social stigmatization, and loss of insurability

Answer 60

Physicians should provide patients with whatever information that will, from the patient’s perspective, have a bearing on medical decision-making and communicate that information in a way that is comprehensible to the patient

Answer 61

An unintended injury or complication from health care management resulting in disablity, death, or prolonged hospital stay

Answer 62

* medical error may be defined as ‘preventable adverse events (AEs)’ caused by the patient’s medical care and not the patient’s underlying illness; some errors may be identified before they harm the patient, so not all error is truly ‘adverse’ * many jurisdictions and professional associations expect and require physicians to disclose medical error; that is, any event that harms or threatens to harm patients must be disclosed to the patient or the patient’s family and reported to the appropriate health authorities • physicians should disclose to patients the occurrence of AEs or errors caused by medical management, but should not suggest that they resulted from negligence because: ■ negligence is a legal determination ■ error is not equal to negligence (see Negligence, ELOM6) * disclosure allows the injured patient to seek appropriate corrective treatment promptly * physicians should avoid simple attributions as to cause and sole responsibility of others or oneself * physicians should offer apologies or empathic expressions of regret (e.g. “I wish things had turn d out differently”) as these can increase trust and are not admissions of guilt or liability * Apology Acts across Canada protect apologies, both as expressions of` regret and admissions of responsibility, from being used as evidence of liability and negligence

Answer 63

• ‘bad news’ may be any information that reveals conditions or illnesses threatening the patient’s sense of well-being • poorly done disclosure may be as harmful as non-disclosure ■ caution patients in advance of serious tests and disclose possible bad findings ■ give time for patient to reflect prior to receiving such news ■ give warnings of impending bad news by reviewing prior discussions ■ provide time for the patient and questions ■ adequate supports and strategies should always be provided following disclosure of difficult news • SPIKES protocol was developed to facilitate “breaking bad news” ■ SETTING and LISTENING SKILL ■ Patient PERCEPTIONS of condition and seriousness ■ INVITATION from patient to receive information ■ KNOWLEDGE - provide medical facts ■ Explore EMOTIONS and EMPATHIZE ■ STRATEGY and SUMMARY

Answer 64

Health care providers have a fiduciary duty to disclose AEs to their patients. Professional societies codify medical providers’ ethical requirement to disclose AEs to patients in accordance with the four principles of biomedical ethics. Transparency and honesty in relationships with patients create opportunities for learning that lead to systems improvements in health care organizations. Disclosure invariably becomes a component of broad systems improvement and is closely linked to improving patient safety.

Answer 65

* may go against certain cultural norms and expectations * may lead to patient harm and increased anxiety * 10-20% of patients prefer not to be informed * medical uncertainty may result in the disclosure of uncertain or inaccurate information

Answer 66

• a patient may waive his/her right to know the truth about their situation (i.e. decline information that would normally be disclosed) when: ■ the patient clearly declines to be informed ■ a strong cultural component exists that should be respected and acknowledged ■ the patient may wish others to be informed and make the medical decisions for him/her * the more weighty the consequences for the patient from non-disclosure, the more carefully one must consider the right to ignorance * ‘emergencies’: an urgent need to treat may legitimately delay full disclosure; the presumption is that most people would want such treatment and the appropriate SDM cannot be found • ‘therapeutic privilege’ ■ withholding of information by the clinician in the belief that disclosure of the information would itself lead to severe anxiety, psychological distress or physical harm to the patient ■ clinicians should avoid invoking therapeutic privilege due to its paternalistic overtones and is a defence of non-disclosure that is rarely accepted anymore ■ it is often not the truth that is unpalatable; it is how it is conveyed that can harm the patient

Answer 67

* discuss in a non-judgmental manner * ensure patients have full access to relevant and necessary information * identify if certain options lie outside of your moral boundaries and refer to another physician if appropriate * consult with appropriate ethics committees or boards * protect freedom of moral choice for students or trainees

Answer 68

* Once outside the mother’s body, the neonate becomes a member of society with all the rights and protections other vulnerable persons receive. * Non-treatment of a neonate born alive is only acceptable if <22 wk GA * 23-25 wk GA: treatment should be a consensual decision between physician and parents * 25 wk GA and more: neonate should receive full treatment unless major anomalies or conditions incompatible with life are present

Answer 69

* in general, maternal and fetal interests align | * in some situations, a conflict between maternal autonomy and the best interests of the fetus may arise

Answer 70

* principle of reproductive freedom: women have the right to make their own reproductive choices * coercion of a woman to accept efforts to promote fetal well-being is an unacceptable infringement of her personal autonomy

Answer 71

• the law upholds a woman’s right to life, liberty, and security of person, and does not recognize fetal rights; key aspects of the mother’s rights include: ■ if a woman is competent and refuses medical advice, her decision must be respected even if the fetus will suffer ■ the fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman

Answer 72

1. medical treatment must never be imposed upon a competent pregnant woman against her wishes 2. no law should be used to confine a pregnant woman in the interest of her fetus 3. the conduct of a pregnant woman in relation to her fetus should not be criminalized 4. child welfare should never be used to control a woman’s behaviour during pregnancy 5. civil liability should never be imposed upon a woman for harm done to her fetus during pregnancy Examples involving the use of established guidelines * a woman is permitted to refuse HIV testing during pregnancy, even if vertical transmission to fetus results * a woman is permitted to refuse Caesarean section in labour that is not progressing, despite evidence of fetal distress

Answer 73

• includes non-coital insemination, hormonal ovarian stimulation, and IVF • topics with ethical concerns: ■ donor anonymity vs. child-centred reproduction (i.e. knowledge about genetic medical history) ■ preimplantation genetic testing for diagnosis before pregnancy ■ use of new techniques without patients appreciating their experimental nature ■ embryo status – the Supreme Court of Canada maintains that fetuses are “unique” but not persons under law; this view would likely apply to embryos as well ■ access to ART ■ private vs. public funding of ART ■ social factors limiting access to ART (e.g. same-sex couples) ■ the ‘commercialization’ of reproduction

Answer 74

The fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman

Answer 75

Payment of gamete donors is currently illegal in Canada. The ART Act is, however, not being enforced currently as it does not clarify whether ART falls under the jurisdiction of the federal or provincial government

Answer 76

* Educate patients and address contributors to infertility (e.g. stress, alcohol, medications, etc.) * Investigate and treat underlying health probems causing infertility * Wait at least 1 yr before initiating treatment with ART (exceptions – advanced age or specific indicators of infertility) * Educate and prepare patients for potential negative outcomes of ART

Answer 77

• pluripotent stem cells can currently be derived from human embryonic and fetal tissue • potential uses of stem cells in research ■ studyng human development and factors that direct ell specialization ■ evaluating drugs for efficacy and safety in human models ■ cell therapy: using stem cells grown in vitro to repair or replace degenerated/destroyed/malignant tissues (e.g. Parkinson’s disease) ■ genetic treatment aimed at altering somatic cells (e.g. myocardial or immunological cells) is acceptable and ongoing

Answer 78

CMA definition of induced abortion: the active termination of a pregnancy before fetal viability (fetus >500 g or >20 wk GA)

Answer 79

1. induced abortion should not be used as an alternative to contraception 2. counselling on contraception must be readily available 3. full and immediate counselling services must be provided in the event of unwanted pregnancy 4. there should be no delay in the provision of abortion services 5. no patient should be compelled to have a pregnancy terminated 6. physicians should not be compelled to participate in abortion – if morally opposed, the physician should inform the patient so she may consult another physician 7. no discrimination should be directed towards either physicians who do not perform or assist at induced abortions or physicians who do 8. induced abortion should be uniformly available to all women in Canada and health care insurance should cover all the costs (note: the upper limit of GA for which coverage is provided varies between provinces) 9. elective termination of pregnancy after fetal viability may be indicated under exceptional circumstances

Answer 80

* no law currently regulates abortion in Canada * it is a woman’s medical decision to be made in consultation with whom she wishes; there is no mandatory role for spouse/family * 2nd and even 3rd trimester abortions are not illegal in Canada, but are usually only carried out when there are serious risks to the woman’s health, or if the fetus has died in utero or has major malformations (e.g. anencephaly)

Answer 81

1. to confirm a clinical diagnosis 2. to detect genetic predisposition to a disease 3. allows preventative steps to be taken and helps patient prepare for the future 4. gives parents the option to terminate a pregnancy or begin early treatment

Answer 82

■ the individual and familial implications ■ its pertinence to future disease ■ its ability to identify disorders for which there are no effective treatments or preventive steps ■ its ability to identify the sex of the fetus ■ ethical issues and arguments regarding the use of prenatal/antenatal genetic testing include: ■ obtaining informed consent is difficult due to the complexity of genetic information ■ doctor’s duty to maintain confidentiality vs. duty to warn family members ■ risk of social discrimination (e.g. insurance) and psychological harm

Answer 83

* no current specific legislation exists * testing requires informed consent * no standard of care exists for clinical genetics but physicians are legally obligated to inform patients that prenatal testing exists and is available * a physician can breach confidentiality terms in order to warn family members about a condition if harm can possibly be prevented via treatment or prevention (e.g. familial adenomatous polyposis)

Answer 84

* thorough discussion and realistic planning with patient before testing is done * genetic counselling for delivery of complex information

Answer 85

Surrogate mothers cannot be paid or offered compensation beyond a reimbursement of their expenses

Answer 86

No one under age 18 can donate sperm or eggs, except for the purpose of creating a child that the donor plans to raise himself/ herself (e.g. young patients receiving radiation therapy for cancer that may cause infertility)

Answer 87

1. Genetic treatment aimed at altering germ cells is prohibited in Canada and elsewhere 2. Embryo research is permitted up to 14 d post-fertilization 3. Embryos created for reproductive purposes that are no longer required may be used 4 Gamete providers must give free and informed consent for research use 5 No commercial transactions in the creation and use of the embryos are permitted 6. Creation of embryos solely for research purposes is prohibited 7. Human cloning is strictly prohibited 8. Risks of coercion must be minimized (i.e. the fertility treatment team may not be pressured to generate more embryos than necessary) 9. One may only discuss the option of using fetal tissue for research after free and informed choice to have a therapeutic abortion has been made by the patient 10. Physicians responsible for fertility treatment may not be part of a stem cell research team

Answer 88

* focus of care is comfort and respect for person nearng death and maximizing quality of life for patient, family, and loved ones appropriate for any patient at any stage of a serious or life-limiting illness * may occur in a hospital, hospice, in the community, or at home * often involves an interdisciplinary team of caregivers * addresses the medical, psychosocial, and spiritual dimensions of care

Answer 89

a deliberate act undertaken by one person with the intention of ending the life of another person to relieve that person’s suffering, where the act is the cause of death

Answer 90

the administering or prescribing for self-administration, by a medical practitioner or nurse practitioner, of a substance, at the request of a person, that causes their death

Answer 91

* patient has the right to make autonomous choices about the time and manner of their own death * belief that there is no ethical difference between the acts of euthanasia/assisted suicide and forgoing life sustaining treatments * belief that these acts benefit terminally ill patients by relieving suffering * patient autonomy has limits * death should be the consequence of the morally justified withdrawal of life-sustaining treatments only in cases where there is a fatal underlying condition, and it is the condition (not the withdrawal of treatment) that causes death

Answer 92

* in Canada, euthanasia is no longer a punishable offence under the Criminal Code of Canada * in the Carter v. Canada decision of February 2015, physician-assisted suicide ruled to be not criminal, with the decision taking effect in 2016, now postponed to June 2016 * until June 2016, applicants for assistance in dying (MAID - ‘Medical Aid in Dying’) must obtain court sanction (as an exemption to the Criminal Code) * Bill C-14 (June 17, 2016) legalized MAID by amending the Criminal Code to create exemptions permitting medical practitioners to provide MAID, specified the eligibility criteria, safeguards, and required documentation and authorization from the Minister of Health, as well as new offences for failure to comply with the new regulations. http://wwwparl.ca/DocumentViewer/en/42-1/bill/C-14/ royal-assent

Answer 93

* patient is eligible for health services funding by government of Canada * at least 18 yr of age, and has capacity for clear and freely given consent * grievous and irremediable medical condition: in an advanced state of irreversible decline in capability * suffering intolerable to the patient, no relieved under conditions they consider acceptable * natural death is reasonably foreseeable

Answer 94

• the use of palliative sedation with opioids in end-of-life care, knowing that death may occur as an unintended consequence (principle of double effect) is distinguished from euthanasia and assisted suicide where death is the primary intent • the appropriate withdrawal of life-support is distinguished from euthanasia and assisted suicide as it is seen as allowing the underlying disease to take its ‘natural course’ but this distinction may be more theoretical than real • consent for withdrawal of life-support must be sought from SDMs, as ruled in Cuthbertson v. Rasouli in 2013 as palliative care would be instituted and consent for that would require SDM consent • refusals of care by the patient that may lead to death as well as requests for a hastened death, ought to be carefully explored by the physician to rule out any ‘reversible factors’ (e.g. poor palliation, depression, poverty, ill-education, isolation) that may be hindering authentic choice • Government of Canada – Services and Information for End-of-Life Care: https://www.canada.ca/en/ health-canada/topics/end-life-care.html ■ options and decision making at end of life: Palliative care, Do not resuscitate orders, Refusal or withdrawal of treatment, Refusal of food and drink, Palliative sedation, MAID ■ decisions at end of life: Informed and capacity for consent, Substitute decision maker, Advanced care planning (written plan, will, or medical directive) often established through a family meeting

Answer 95

• physicians are required by law to complete a medical certificate of death unless the coroner needs notification; failure to report death is a criminal offence • Coroner’s Act, 1990 (specific to Ontario, similar in other provinces) requires physicians to notify a coroner or police officer if death occurs: ■ due to violence, negligence, misconduct, misadventure, or malpractice ■ during pregnancy or is attributable to pregnancy ■ suddenly and unexpectedly ■ from disease which was not treated by a legally qualified medical practitioner ■ from any cause other than disease ■ under suspicious circumstances • coroner investigates these deaths, as well as deaths that occur in psychiatric institutions, jails, foster homes, nursing homes, hospitals to which a person was transferred from a facility, institution or home, etc in consultation with forensic pathologists and other specialists, the coroner establishes: ■ the identity of the deceased ■ where and when the death occurred ■ the medical cause of death ■ the means of death (i.e. natural, accidental, suicide, homicide, or undetermined) * coroners do not make decisions regarding criminality or legal responsibility * unclear as yet whether physicians who object to MAID on grounds of conscience will have to refer to willing physicians, and also unclear what patients seeking MAID in religious affiliated hospitals will do

Answer 96

* Violence, negligence, misconduct * Pregnancy * Sudden or unexpected causes * Disease not treated * Cause other than disease * Suspicious circumstances

Answer 97

Pursuit of aid in dying does not have negative effects on surviving family members and may be associated with greater preparation and acceptance of death.

Answer 98

* Respect competent decisions to forgo treatment * Provide appropriate palliative measures * Decline requests for euthanasia and assisted suicide * Try to assess reasons for such requests from patients to see if there are ‘reversible factors’ (such as depression, pain, loneliness, anxiety) that can be treated

Answer 99

* physicians’ conduct and competence are legally regulated to protect patients and society via mandatory membership to provincial governing bodies (e.g. the CPSO) * physicians are legally required to maintain a license with the appropriate authority, and are thus legally bound to outlined policies on matters of conduct within his/her medical practice * the ultimate constraint on MD behaviour with regards to unprofessionalism is ‘conduct unbecoming a physician’, such as inappropriate behaviour with colleagues, conflicts of interest, untruthfulness, unethical billing practices, and sexual impropriety with patients

Answer 100

• physicians must ensure that patients have access to continuous on-call coverage and are never abandoned

Answer 101

• sexual conduct with patients, even when consented to by the patient, is a serious matter that can lead to accusations of battery by the patient and provincial governing body. Important notes on this topic include: ■ inappropriate sexual conduct includes intercourse, undue touching, references to sexual matters, sexual jokes, and physician presence when capable patients undress or dress ■ in specified situations, physicians may have a personal relationship with a patient provided a year has passed since the last therapeutic contact ■ physicians are permanently prohibited from personal relationships with patients whom they saw for psychotherapy ■ in Ontario, physicians must report any colleagues of whom they have information regarding sexual impropriety (as per CPSO Code of Ethics)

Answer 102

• physicians must maintain adequate records for each patient, which include: ■ demonstration that care has been continuous and comprehensive ■ minimal standards for record-keeping, including readability, diagnosis, differential diagnosis, appropriate tests and referrals, and a coherent patient record, including drugs, a Cumulative Patient profile, all aspects of charting that are required for safe patient care (full standards available at www. cpso.on.ca). Another physician should be able to take over the safe care of the patient based on the record ■ records stored for 10 years in most jurisdictions ■ although the medical record is the property of the physician or an institution, the patient or the patient’s delegate must be allowed full access to information in the medical record in a reasonable period of time, and can charge a reasonable fee, upon (usually written) request

Answer 103

• in the hospital, physicians must ensure their own competence, respect hospital by-laws and regulations, practice only within the limits of granted privileges, cooperate with other hospital personnel, and maintain adequate hospital records

Answer 104

* Communicator * Collaborator * Health Advocate * Leader * Professional * Scholar * Medical Expert

Answer 105

Discontinuing services that are needed is an act of professional misconduct unless done by patient request, alternative services are arranged, or adequate notice has been given

Answer 106

CMA Code of Ethics Report any unprofessional conduct by colleagues to the appropriate authority

Answer 107

Physicians will not diagnose or treat themselves or family members except for minor conditions or in emergencies and then only if no other physician is readily available

Answer 108

• involves the systematic analysis of ethical dilemmas arising during research involving human subjects to ensure that: ■ study participants are protected ■ clinical research is conducted to serve the interests of the participants and/or society as a whole * major ethical dilemmas arise when a physician’s obligation to the patient comes into conflict with other obligations and incentives * any exceptions to disclosure for therapeutic consent do not apply in an experimental situation * important ethical principles to consider when conducting research on human subjects are laid out in the Declaration of Helsinki, the Belmont Report, and the Tri-Council Policy Statement: Ethical Conduct on Research Involving Human Subjects

Answer 109

Patient’s participation in research should not put him/her at a known or probable disadvantage with respect to medical care (i.e. cannot deny participants in research ‘known effective care’, such as randomizing some depressed patients to a placebo arm with no treatment) Participant’s voluntary and informed choice is usually required, except in special circumstances (i.e. chart reviews without patient contact, or emergency situations for which there is no accepted or helpful standard of care and the proposed intervention is not likely to cause more harm than such patients already face) Access to the treatment that is considered standard (i.e. placebo controlled trials are generally acceptable where patients all receive stil receive the standard of care, or, if not, are informed about the placebo arm and what that entails) Must employ a scientifically valid design to answer the research question (ensured via peer review, expert opinion) Must demonstrate sufficient value to justify any risk posed to participants Must be conducted honestly (i.e. carried out as stated in the approved protocol) Findings must be reported promptly and accurately without exaggeration, to allow practicing clinicians to draw reasonable conclusions Patients must not be enticed into risky research by the lure of money and investigators must not trade the interests of patients for disproportionate recompense by a sponsor; both participants and investigators are due fair recompense for their time and efforts Any significant interventonal trial ought to have a data safety monitoring board that is independent of the sponsor and can ensure safety of the ongoing trial

Answer 110

* health care delivery in Canada involves collaboration between physicians and the pharmaceutical and health supply industries in the areas of research, education, and clinical evaluation packages (i.e. product samples) * physicians have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their duties to their patients and society • gifts or free products from the pharmaceutical industry are usually inappropriate: ■ sponsorship for travel and fees for conference attendance may be accepted only where the physician is a conference presenter and not just in attendance ■ physicians receiving such sponsorship must disclose this at presentations and/or in written articles

Answer 111

the distribution of goods and services to programs and people

Answer 112

• physicians have the duty to inform patients about therapeutic options even if they are not available • physicians must make health care resources available to patients in a manner which is fair and equitable, without bias or discrimination ■ need and benefit are morally relevant criteria for resource allocation ■ gender, sexual orientation, religion, level of education, or age alone are morally irrelevant criteria • ethical dilemmas that arise when deciding how best to allocate resources ■ fair chances vs. best outcome: favouring best outcome vs. giving all patients fair access to limited resources (e.g. transplant list prioritization) ■ priorities problem: how much priority should the sickest patients receive? ■ aggregation problem modest benefits to many vs. significant benefits to few ■ democracy problem: when to rely on a fair democratic process to arrive at a decision

Answer 113

* Respect for persons: informed consent * Beneficence: harm vs. benefit * Justice: avoid exploitation/unjustified exclusio

Answer 114

* Purpose of study * Sum of funding * Name and probability of harm and benefits * Nature of physician’s participation including compensation * Proposals for research must be submitted to a research ethics board

Answer 115

Randomization is allowed even if there is an efficacious standard if, for example, there are drawbacks to it (such as it doesn’t work for all, has side effects, and is not wanted by all patients). In such cases, there must be a good safety net established to make sure subjects in the placebo arm do not deteriorate (i.e. there must be a safety monitoring plan for such studies)

Answer 116

* The primary goal should be the advancement of the health of Canadians * Relationships should be guided by the CMA Code of Ethics * The physician’s primary obligation is to the patient * Physicians should avoid any self-interest in their prescribing and referral practices * Physicians should always maintain professional autonomy, independence, and commitment to the scientific method

Answer 117

* Identify their resuscitation options (CPR or DNR), if applicable * Check for documentation of advance directives and POA where applicable

Answer 118

* Identify the primary decision-maker (parents, guardian, wards-of-state, emancipated) * Regarding capacity assessment see Pediatric Aspects of Capacity Covered, ELOM10 * Be wary of custody issues if applicable

Answer 119

* Consider the SPIKES approach to breaking bad news * What are his/her goals of care (i.e. disease vs. symptom management)? * Identify advance directives, POA, or SDM, if applicable (see ELOM10) * Check for documentation of resuscitation options (CPR or DNR) and likelihood of success

Answer 120

* If not already present, perform a formal capacity assessment * Identify if the patient has a SDM or who has their POA * Check the patient’s chart for any Mental Health Forms (e.g. Form 1) or any forms they may have on their person (e.g. Form 42)

Answer 121

• the physician’s primary obligation is to: ■ protect and promote the welfare and best interests of his/her patients ■ choose interventions known to be beneficial on the b sis of evidence of effectiveness ■ seek the tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost ■ advocate for one’s patients, but avoid manipulating the system to gain unfair advantage for them ■ resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria such as need and benefit, using fair and publicly defensible procedures ■ inform patients of the impact of cost constraints on care, but in a sensitive way ■ seek resolution of unacceptable shortages at the level of hospital management or government

Answer 122

• in accordance with the principle of autonomy, it is generally acceptable for competent patients to refuse medical interventions for themselves or others, although exceptions may occur • if parents or SDMs make decisions that are clearly not in the “best interests” of an incapable child, physicians may have ethical grounds for administering treatment, depending on the acuity of the clinical situation ■ in high-acuity scenarios (e.g. refusing blood transfusion based on religious grounds for a child in hemorrhagic shock), physicians have a stronger obligation to act in the child’s best interests ■ in lower acuity scenarios (e.g. refusing childhood immunization in a developed nation) there is a stronger obligation to respect the autonomy of the decision-makers ■ pursuing traditional First Nations healing (in conjunction or in the place of standard biomedical therapy) is legally considered a constitutionally protected right, which can be made by a SDM, as ruled in Hamilton Health Sciences v. DH in 2014

Answer 123

• physicians may refuse to provide treatment or discontinue relationships with patients, but must ensure these patients can access services elsewhere (e.g. a pediatrician who refuses to treat an unvaccinated child should refer the family to another practice)

Answer 124

• Aboriginal peoples collectively refers to original inhabitants of Canada and their descendants: First Nations, Inuit, and Métis peoples defined in the Canadian Constitution Act, 1982 ■ First Nations people encompasses most of geographic Canada and constitutes many distinct communities and languages. ■ Inuit peoples refers to original inhabitants of arctic regions including Labrador, northern Quebec, Nunavut, and Northwest Territories. ■ Métis are historic people of mixed First Nations and European heritage ■ Canada’s Indian Act, 1976, defined who is considered a “status Indian” and thus eligible for programs and services by federal and provincial agencies. Non-Status First Nations, are Aboriginals who are not a “Registered Indian” with the federal government ■ the Daniels Decision, 2013 Federal Court of Canada, deemed Métis and non status be considered “Indians” under Canadian Constitution Act

Answer 125

• Aboriginal Health Policy in Canada is made up of a complicated “patchwork” of policies, legislation and agreements between federal, provincial, municipal, and Aboriginal governments which is in a constant state of flux; reviewed by the National Collaborating Centre for Aboriginal Health (NCCAH): http:// www.nccah-ccnsa.ca/en/publications.aspx?sortcode=2.8.10&publication=28 ■ while some Aboriginal health services are adequate, gaps and ambiguities created by complicated policy and jurisdictions have created barriers to health equity ■ for majority of Métis, off-reserve, and non-status Indians, health services are financed through the National Health Insurance plan administered at the provincial and territorial level ■ for on-reserve First Nations and Inuit, the federal government finances and administers health services through the First Nations and Inuit Health Branch (FNIHB) ■ the Indian Health Policy, 1979, and Health Transfer Policy, 1989, transferred control to individual communities to negotiate with the FNIHB varying levels of health care responsibility to the community or council level ■ treaties and Self Government Agreements define areas of jurisdiction for federal, provincial/ territorial, and Aboriginal governments ■ in general, multiple levels of authority and responsibility are involved with the general tendency towards delegating responsibility to local levels