Special Considerations

Special Considerations

In the unfortunate circumstance that this conversation does not occur between the patient and attending physician and you’re confident the patient made an informed decision regarding CPR, under your professional obligation, CRTO policy and the CRTO’s understanding of the Health Care Consent Act’s intent you have an obligation to not initiate this intervention (CPR) and express the patient’s wishes to the health care team. Conversely, if you are not confident that the patient made an informed decision, then you would participate in CPR.


What should I do if a capable patient/client indicates to me that they would not want any heroic measures to save their life – such as cardiopulmonary resuscitation (CPR) – but before the attending physician can write a “Do not resuscitate” order the patient suffers a cardiac/respiratory arrest?

What do you do?

In order to follow-through on patient’s/client’s wishes regarding CPR, it is imperative that the attending physician has a discussion with the patient/client as soon as possible. In the meantime, the CRTO recommends that you take the following actions:

  1. At the time that a patient/client makes a statement indicating they do not want life saving measures, explain the nature of the treatment intervention (CPR), expected benefits, risks and the consequences of not receiving CPR if it is required to the patient. You may also want to briefly explain what’s meant by CPR: e.g. intubation, ventilation, compressions, and defibrillation/cardioversion to establish that the patient/client has made an informed decision about what treatment they are declining.
  2. Notify the attending physician immediately and describe what the patient/client has stated.
  3. Ask another health care professional, preferably the patient’s/client’s nurse to witness what the patient has just articulated.
  4. Document a description of the conversation you had with the patient/client in their chart.
  5. Follow-up with the attending physician and confirm the resuscitation status of the patient/client.

It is important to recognize and acknowledge that patients/clients may not fully comprehend or appreciate the consequences of not having this life saving intervention. (N.B., understanding and appreciating information are different concepts. Understanding is cognitive. Appreciating information means that patient/client grasps the practical implications of their decision. Informed consent requires both comprehending and appreciating the consequences of the decision.) To that end, it is very important that the patient’s attending physician has the opportunity to discuss the likelihood of requiring CPR, the nature of the treatment, expected benefits, risks, alternative treatment options and the consequences of not receiving CPR if required.

Substitute Decision Maker (SDM)

A Substitute Decision Maker (SDM) is an individual who may give or withhold consent on behalf of an incapacitated patient/client. The following list of SDMs is in order of priority rank:


1. Guardian of the person, if they have authority to give or refuse consent to the treatment


2. Attorney for personal care, if they have the authority to give or refuse consent to the treatment


3. Representative appointed by the Consent and Capacity Board, if the representative has the authority to give or refuse consent to the treatment


4. Spouse or partner


5. Child or parent of the incapable person or children’s aid society or other guardian in place of a parent — this does not include a parent who only has right of access


6. A parent with right of access only


7. A brother or sister


8. Any other relative


9. The Public Guardian and Trustee [HCCA, section 20]

The substitute decision-maker must be:




at least 16 years old, unless they are the parent of the incapable person;


not prohibited by court order or separation agreement from having access or giving or refusing consent;


available; and


willing to assume responsibility

[HCCA, section 20].

The SDM must also:


believe that no other person from a higher priority of substitute decision — maker exists, or if they exist they would not object to them making the decision — if there is an individual who is from priority rank 1, 2, or 3 then this decision-maker must be the person making decisions;


give or refuse consent in accordance with any known wishes expressed by the incapable person when capable and at least 16 years old; and


act in the best interests of the incapable person if no wishes are known or it is impossible to comply with them

[HCCA, section 21].

Where there are two individuals of the same priority of substitute decision-maker who disagree about whether to give or refuse consent for a treatment (and if their rank is ahead of any other potential substitute decision-maker), the Public Guardian and Trustee must then make the decision.

Consent Capacity Board (CCB)

A person who is found to be incapable may apply for a review of the finding to the Consent and Capacity Board [HCCA, s. 32]. The only exception to this right is if the person has a guardian with the authority to give or refuse consent to treatment, or the person has an attorney for personal care and the power of attorney waives the person’s right to apply for a review [HCCA, s. 32].

Except in an emergency, you must not begin a treatment or procedure, and you must take reasonable steps to ensure that the treatment or procedure is not started, following a finding of incapacity until:


48 hours after you were first informed of an intended application to the Consent and Capacity Board, without an application to the Board being made;


the application to the Board has been withdrawn;


the Board has rendered its decision and none of the parties [HCCA, s. 32 and 33] have indicated their intention to appeal;


the time for initiating an appeal from a Board decision has expired without an appeal being launched after a party to the application has informed you that they intend to appeal; or


the appeal of the Board decision has been finally disposed of. [HCCA, s. 18].

What are the Penalties for Failure to Comply with the Consent Legislation?

The HCCA provides protection from liability for health care practitioners who act in their belief, on reasonable grounds and in good faith, that there was consent for the actions they took [HCCA, section 29]. While it may be reasonable to presume that consent has been given unless you have overt signs that it wasn’t, the CRTO recommends that you verify consent for any
controlled act you perform, as a minimum.

It is professional misconduct to do “anything to a patient or client for a therapeutic, preventative, palliative, diagnostic, cosmetic or health-related purpose in a situation in which a consent is required by law, without such a consent” [O. Reg 753/93 – Professional Misconduct, paragraph 3].

A Member found guilty of professional misconduct may be subject to any one or more of the following [HPPC, s. 51(2)]:


1. Revocation of the registrant’s certificate of registration;


2. Suspension of the registrant’s certificate of registration for a specified period of time;


3. Imposition of terms, limitation or conditions on the registrant’s certificate of registration for a specified or indefinite period of time;


4. Appearance before the panel for a reprimand;


5. A fine of up to $35,000, payable to the Minister of Finance.


Attorney for personal care: An attorney under a power of attorney for personal care given under the Substitute Decisions Act.

Consent and Capacity (the board): A board established by and accountable to the government. Its members are appointed by the government. The Board considers applications for review of findings of incapacity, applications relating to the appointment of a representative, and applications for direction regarding the best interests and wishes of an incapable person.

Capable: Means mentally capable; a person is capable if they are able to understand the information that is relevant to making a decision about the treatment and are able to appreciate the reasonable foreseeable consequences of a decision or lack of decision — capacity has a corresponding meaning.

College: College of Respiratory Therapists of Ontario.

CRTO: College of Respiratory Therapists of Ontario.

Emergency: When the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk, if the treatment is not administered promptly, of sustaining serious bodily harm.

Guardian of the Person: A guardian of the person appointed under the Substitute Decisions Act.

HPPC: Health Professions Procedural Code — Schedule 2 of the Regulated Health Professions Act.

Incapable: Mentally incapable with incapacity having a corresponding meaning.

Partners: Individuals who have lived together for at least one year and have a close personal relationship that is of primary importance in both lives.

Plan of Treatment: A plan that:

      • is developed by one or more health practitioners
      • deals with one or more health problems that an individual has, and may deal with one or more problems an individual is likely to have in the future given their current health
      • allows for administration of various treatments or courses of treatment.

Relatives: Related by blood, marriage or adoption.

Respiratory Care: Equivalent to Respiratory Therapy.

Respiratory Therapist (RT): A Member of the CRTO and includes Registered Respiratory Therapists (RRT), Practical (limited) Respiratory Therapist (PRT) or Graduate Respiratory Therapists (GRT).

Spouses: Individuals who are married to each other, or who are living in a conjugal relationship and have lived together for at least one year, have a cohabitation agreement or are the parents (together) of a child. Individuals living apart and separate are not spouses.

Treatment: Means anything that is done for a therapeutic, preventative, palliative, diagnostic, cosmetic or other health-related purpose, and includes a course of treatment or plan of treatment, but does not include:

      • assessment of a person’s capacity
      • assessment or examination to determine the general nature of an individual’s condition
      • taking a health history
      • communicating an assessment or diagnosis
      • admission to a hospital or other facility
      • a personal assistance service
      • a treatment that, in the circumstances, poses little or no risk of harm
  1. College of Nurses of Ontario (2017). Practice Guideline: Consent. Retrieved from: (
  2. Health Care Consent Act (1996).  Retrieved from: Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A (
  3. Health Protection and Procedure Act (1990). Retrieved from: R.R.O. 1990, Reg. 569: REPORTS (
  4. Regulated Health Professions Act, 1991, S.O. 1991, c. 18. Retrieved from: Regulated Health Professions Act, 1991, S.O. 1991, c. 18 (