CMTBC has developed a new standard of practice on consent. This proposed standard of practice contains:

• Detailed requirements for RMTs to follow when obtaining consent from patients;
• An appendix with defined terms;
• Requirements for application to practice when determining a patient’s capacity to give consent, obtaining consent from minors, communicating during the consent process, and documenting consent;
• A summary of relevant legislation.

The CMTBC Board has approved the release of the proposed standard of practice to the profession and the public for an eight-week notice period, from August 27 to October 22, 2018. During the notice period, any RMT or member of the public may submit comments about the proposed standard of practice by email to standardsfeedback@cmtbc.ca.

The College will consider all comments received before submitting the standard of practice to the CMTBC Board for final approval in November 2018. 

Read the news story about the proposed standard of practice on consent.

Proposed Standard of Practice on Consent

Purpose

Practice standards define the minimum level of expected performance for registered massage therapists, and therefore define what constitutes safe, ethical, and competent delivery of care by RMTs.

RMTs are responsible for exercising their professional judgment to apply the standards to the situations that they face in practice.                        

Consent

Definition

Consent is a cornerstone of patient-centered care. Informing patients and involving them in decisions about their treatment is integral to care delivery.

Obtaining consent requires ongoing communication between the RMT and the patient.  It is the RMT’s legal and professional responsibility to make sure that this communication occurs, and that the patient’s consent is both informed and voluntary. Patient consent supports good clinical decision-making, patient safety, and predictable and desired treatment outcomes.

In addition to RMTs’ professional obligations, there are two statutes in British Columbia that set out legal requirements for patient consent. The Health Care (Consent) and Care Facility (Admission) Act (the “Consent Act”) defines the scope and elements of consent for adults (individuals aged 19 and older). The Infants Act sets out the requirements for obtaining consent from a minor or “infant” (legally defined as an individual under the age of 19 years). These statutes are described in the last section of this standard, Relevant Legislation.

Note: This standard applies only to consent for delivery of massage therapy. It does not apply to consent for collection, use or disclosure of patients’ personal information, which is governed by different legal and ethical obligations. It also does not apply to obtaining consent to participate in research.

Requirements

The requirements below apply to all patients unless the requirements are stated to be age-specific (either 19 years of age or older, or under 19 years of age).  

1. An RMT recognizes, respects and supports each patient’s right to make decisions about the patient’s own health care by:
   1. engaging in shared decision-making with the patient; and
   2. respecting the patient’s autonomy.
2. In obtaining consent, an RMT acts with integrity and in the patient’s best interests, and does not use coercion, fraud or misrepresentation.
3. An RMT:
   1. obtains consent prior to delivery of massage therapy (including assessment, treatment and re-assessment);
   2. monitors and renews consent where appropriate throughout treatment; and
   3. discontinues treatment if the patient withdraws consent.
4. An RMT provides sufficient information to enable the patient, (or, where required, parent or legal guardian or substitute decision-maker) to make an informed decision by:
   1. communicating whether the RMT is:
      1. conducting an initial intake of the patient,
      2. creating a treatment plan,
      3. assessing the patient,
      4. delivering massage therapy during a first session,
      5. delivering massage therapy during a subsequent session, or
      6. instructing the patient in home care;
   2. providing information about areas of the patient’s body where treatment will be delivered, the anticipated benefits and possible negative effects of the treatment, the therapeutic rationale for the proposed treatment, whether it is necessary for the patient to remove clothing, and explaining how the patient will be draped during the treatment; and
   3. communicating in a way that is appropriate to the patient’s level of understanding, considering factors such as the patient’s age, language and cultural background. This is done in accordance with the guidance set out in the application to practice section of this standard.
5. On initial intake, an RMT shows the patient (or, where required, a parent, legal guardian, or substitute decision-maker) a consent form that describes massage therapy including assessment, treatment, home care, and re-assessment and discusses the consent form with the patient before asking for the patient’s signature.
6. An RMT offers to provide the patient (or, if required by statute, a parent, legal guardian, or substitute decision-maker) with a copy of the signed consent form and retains the original signed consent form in the health care record for that patient.
7. When creating a treatment plan, an RMT addresses the patient’s goal(s) and expectation(s) in seeking massage therapy.
8. During treatment, an RMT is aware of and responsive to any indication that the patient wishes to ask questions, or to modify or end the treatment.
9. An RMT communicates about pain and pressure during treatment and modifies treatment as necessary in response to verbal or non-verbal indications of pain or discomfort from the patient.
10. Before the delivery of a subsequent treatment, an RMT renews consent if appropriate.
11. If renewal of consent is not necessary before the delivery of a subsequent treatment, an RMT reminds the patient to ask questions about the treatment at any time, or to end the treatment at any time if the patient feels uncomfortable.
12. An RMT renews consent when the treatment approach changes for any reason, and revises the treatment plan or creates a new one.
13. During delivery of a subsequent treatment, an RMT asks about the patient’s reaction to the previous treatment.
14. An RMT documents the patient’s consent, both initial and ongoing, or refusal to consent in the health care record for that patient. This is done in accordance with the guidance set out in the application to practice section of this standard.
15. An RMT understands and follows the legal requirements set out in the Consent Act and the Infants Act.
16. When the patient is 19 years of age or older, an RMT determines the patient’s capacity to give consent in accordance with the Consent Act. If necessary, an RMT will identify the individual who is authorized and able to make health care decisions on the patient’s behalf (the substitute decision-maker). This is done in accordance with the guidance set out in the application to practice section of this standard.
17. When the patient is under 19 years of age, an RMT determines whether the patient can consent to the patient’s own treatment. If necessary, the RMT identifies the parent(s) or legal guardian(s) who may consent on the patient’s behalf. This is done in accordance with the guidance set out in the application to practice section of this standard.

Appendix – Defined Terms

Substitute decision-maker: A person who is authorized to make health care decisions on another person’s behalf as one of the following:

• a “temporary substitute decision-maker” under section 16 of the Consent Act;
• a “committee” under section 1 of the Patients Property Act; or
• a representative who, under a representation agreement, is authorized to make the particular health care decision.

Application to Practice

Determining Capacity to Give Consent

Section 16 of this standard requires an RMT to determine the patient’s capacity to give consent in accordance with the Consent Act, where the patient is 19 years of age or older.

The RMT must presume that the patient is capable of giving, refusing, or revoking consent to health care unless there is a reason to believe otherwise.

A patient is seen to be capable of giving consent if the patient is able to:

• understand the information that is relevant to making a decision about the proposed care, including how the information applies to the patient’s situation; and
• appreciate the reasonably foreseeable consequences of a decision or lack of decision.

Some strategies to apply during the process of determining capacity include:

• remembering that incapacity in one legal area does not necessarily imply incapacity in another;
• assessing capacity more than once to accommodate fluctuations in the person’s cognitive abilities; and
• considering whether to seek assistance from the patient’s family or the patient’s general physician.

Obtaining Consent from Minors

Section 17 of this standard requires an RMT to determine whether a patient under 19 years of age is able to consent to the patient’s own treatment under the Infants Act, as a mature minor.

The RMT must understand the legal requirements for determining if a minor patient is able to give consent to the minor’s own health care and know who may give consent if the minor cannot.

A mature minor’s consent is sufficient if the RMT is satisfied that the minor understands the nature, consequences, and reasonably foreseeable benefits and risks of the proposed health care.

However, it is still the responsibility of the RMT to make reasonable efforts to ensure that the treatment serves the minor patient’s best interests.  The RMT cannot obtain valid consent unless the treatment serves the minor patient’s best interests.

When determining whether the minor is capable of consenting to the minor’s own health care, the RMT should:

• consider:
  • the age and maturity of the minor;
  • the nature of the proposed massage therapy and the area of the body where the proposed treatment would be delivered;
  • the condition or impairment for which massage therapy is proposed;
• discuss (with the minor):
  • the condition or impairment for which massage therapy is proposed;
  • the areas of body where the proposed massage therapy would be delivered, whether it would be necessary to remove clothing, and explain how the minor would be draped during the treatment;
  • the nature, the anticipated positive effects of the proposed treatment, and any anticipated negative effects that may be associated with the proposed treatment;
  • the therapeutic rationale for the proposed treatment approach;
  • alternatives to the proposed treatment approach;
• ask open-ended questions to determine the minor’s level of understanding;
• give the minor time to think over the information provided;
• invite questions; and
• consider whether the proposed massage therapy serves the minor’s best interests.

The RMT must then assess whether the minor has understood the discussion, whether the minor is capable of providing consent, and whether the proposed massage therapy serves the minor’s best interests.

If the minor is not capable of providing consent, the RMT must obtain consent from the patient’s parent(s) or legal guardian(s).

Communication During the Consent Process

Section 4(c) of this standard requires an RMT to communicate in a way that is appropriate to the patient’s level of understanding.

RMTs can strengthen their communications by giving explanations in ways best understood by the patient and by using a combination of strategies. These might include:

• giving verbal explanations;
• using visual aids and handouts;
• asking patients for feedback about what they understand;
• asking patients if they have any questions;
• engaging any family or friends who are supporting the patient to help the patient understand;
• using plain language and age-appropriate terminology;
• using the services of a qualified interpreter if a language barrier exists; and
• providing information through an alternate mode (e.g., using sign language or speaking in the patient’s mother tongue).

Documenting Consent

Section 14 of this standard requires the RMT to document the patient’s consent, both initial and ongoing, or refusal to consent, in the health care record for that patient.

Documentation should reflect the consent process, and include:

• confirmation that criteria for valid consent were met;
• when and how consent was obtained;
• concerns raised during the consent process, and actions taken to address concerns;
• reason for refusal or withdrawal from massage therapy services; and
• reasons for determining that a patient was not capable of making an informed decision, and action taken to identify a parent/guardian or substitute decision-maker.

Relevant Legislation

The following is a summary of the relevant legislation: the Health Care (Consent) and Care Facility (Admission) Act (the “Consent Act”) and the Infants Act. It is a summary only and cannot be relied on as legal advice.

It is not part of CMTBC’s standard of practice, but rather a summary intended to assist RMTs with their obligation to understand and follow the legal requirements set out in the Consent Act and the Infants Act.

Consent Act

The Consent Act applies only to adults (individuals are 19 years of age or older). There are different requirements for individuals under the age of 19 years, which are described under the heading Infants Act below.

Patients’ rights over their own person, and their rights not to have their person interfered with, is considered so important that the RMT must be able to prove that the patient provided consent. Consent can be withdrawn at any time, and the decision must be respected.

Under the Consent Act, the RMT must obtain consent directly from the patient. There are a few exceptions, including:

1. when an RMT has decided that a patient is incapable of providing consent, and consent is provided by a substitute decision-maker;
2. when there is an urgent or emergency health care situation; and
3. when a patient is thought by others to be incapable, and a spouse or relative of the patient gives substitute consent.

Under the Consent Act, valid consent is obtained only if all of the following elements are present:

1. Consent relates to the proposed massage therapy;
2. Consent is given voluntarily;
3. Consent is not obtained through misrepresentation or by fraud;
4. The patient is capable of making a decision about whether to receive or refuse the proposed health care;
5. The health care provider informs the patient by providing all information that a reasonable person would require to understand the proposed treatment and to make a decision, including information about:
   1. the condition or impairment for which massage therapy is proposed,
   2. the nature of the proposed treatment (for example, what techniques or modalities is the RMT proposing to use, what do they involve, and how they address the patient’s condition),
   3. the risks and benefits of the proposed treatment that a reasonable person would expect to be told about,
   4. alternatives to the proposed treatment approach, including alternatives available from other professions where expressly indicated; and
6. The patient has an opportunity to ask questions and receive answers about the proposed treatment.

Point 5, above, refers to the concept of a “reasonable person”. What information would a reasonable person need? The scope of information that must be given varies with each situation. RMTs should make reasonable efforts to find out about the patient’s concerns and personal circumstances that might be relevant to the patient’s information needs, and present information in a manner that is unique to the patient’s circumstances.

Infants Act

The Infants Act sets out different requirements for obtaining consent from an “infant” or minor (legally defined as an individual under the age of 19 years).

While the Infants Act uses the term “infant” to describe all minors, it provides rules to determine who qualifies as “mature” minors and who are entitled to give consent to their own health care. 

Mature minors can consent to their own treatment on the condition that the RMT providing treatment has:

1. explained the nature, consequences, and reasonably foreseeable benefits and risks of massage therapy,
2. been satisfied the patient understands these benefits and risks; and
3. made reasonable efforts to determine that massage therapy and a proposed treatment plan is in the patient’s best interests.

If one or more of these conditions has not been met, the patient is not a mature minor and cannot consent to the patient’s own treatment.