PROMOTING QUALITY PRACTICE

Right to refuse client referrals

College of Occupational Therapists of Ontario
August 1998

Practice Scenarios:

1. I work in mental health and often engage in long-term, supportive counselling interventions. I have seen a client for an initial interview and realize that I will likely have some countertransference issues with this particular client. Do I have to continue to work with him, or can I now refuse to provide service?

2. I have a small private practice as well as working at the local hospital. My supervisor at the hospital has asked me to see her son in my private practice. He was in a motor vehicle accident and requires equipment that she is concerned the insurance company will not approve. I am reluctant to refuse the referral for fear it may impact on my job.

3. I am the only OT in my community and I have just received a referral for an individual with AIDS. I have not worked with someone who has AIDS and I am very anxious about it. Do I have to accept this referral?

4. I have received a referral for a client who I have heard has a history of being litigious. I do not want to take the risk of a problem with my business. Is it acceptable to refuse the referral?

Probing Questions

1. Is it acceptable to refuse to accept a referral? What must be considered in making this decision?

2. At what point must I decide if I want to accept the referral? How do I communicate my decision?

3. Are there some situations when it is most appropriate to refuse a referral?

Discussion

As an independent practitioner, an occupational therapist is free to identify the clients for whom she or he will provide intervention. Once a referral is received, the therapist needs to review it and determine if she or he wishes to accept it. Before making this decision, there are several issues the therapist will want to address in order to determine the appropriate action.

Accepting or refusing to accept the referral is not necessarily a simple decision. It is not only a matter of determining if the therapist can manage a new client in the caseload. There are ethical, regulatory, legal and employment issues to consider. In some situations it will be most appropriate to accept the referral, and sometimes it will be more appropriate to refuse to accept the referral. Careful consideration of the facts to determine if there is any information which will influence the decision in one direction or the other is necessary. During the decision-making process, the occupational therapist should use a systematic approach.

Regulatory Issues

All therapists must take into consideration conflicts of interest, personal competency and rules for discontinuation of service.

Conflict of Interest

Upon receipt of a referral, it is necessary for the therapist to identify her or his self-interests and determine if there is a conflict of interest which would be cause to refuse the referral. Occupational therapists engage in professional misconduct if they practise the profession while in a conflict of interest (Professional Misconduct Regulation, paragraph #8). A conflict can be defined as the therapist having a relationship as a result of which a reasonable person would conclude that the personal interests of the member improperly influences, or is likely to improperly influence, the member's professional judgement or conflict with the member's duty to act in the best interests of the client. Conflicts are often clear and readily evident, but may also be more obscure or perceived.

For example, it is clear that the emotion involved in provision of service to an immediate family member may well preclude the therapist from making objective treatment decisions and is therefore not recommended. However, these kinds of conflicts are not unique to family relationships. There will be times when the nature of other relationships also provides cause for concern. Each situation must be examined to determine if the nature of the relationship is such that it could influence your judgement or could be seen by others to influence your judgement. If there is such a conflict, or potential conflict, then the therapist would be wise to refuse the referral.

Competency

Each occupational therapist is responsible for ensuring they are competent to provide service to clients (Professional Misconduct Regulation, paragraph #2). If a therapist receives a referral for a service that is beyond his or her current knowledge, skill and ability, then he or she must identify their limitations and seek out and utilize assistance and resources to provide the necessary service. If this is not possible, the OT should refer the client on to other appropriate professional services.

Discontinuation of Service

It will not always be possible to determine a conflict or a limitation in competency solely on review of the referral without meeting the client. Therapists may initiate a process of data collection and assessment which then reveals concerns for continuation of intervention. If the therapist is in a screening stage and has not initiated a relationship with the client, then it would be acceptable to choose not to accept the referral if that is the decision made. However, if assessment or intervention has been started, and the therapist would be seen to have accepted the referral, then the therapist must follow an appropriate discharge process (Professional Misconduct Regulation, paragraph #6). In either event, the therapist is responsible for communicating clearly with the client and referral source, including written documentation. It should be noted that poor communication between therapist and client is often the cause of complaints to the College.

ETHICAL DILEMMAS

In addition to College regulations, therapists must always consider the ethical obligation they have to the public. The Regulated Health Professions Act provides a framework to ensure the public receives service from qualified and ethical professionals. One of the goals of the Act is to ensure that individuals are treated with sensitivity and respect.

Ethical dilemmas present themselves frequently. Decisions must often be made in the face of conflicting views or information which is not immediately evident. These are not easy decisions to make and there is not one specific method of solving the dilemma. Clearly, a problem-solving approach that considers all relevant information is required. The College's Standards of Practice provides a decision-making framework that considers client's needs, the profession's code of ethics, the evidence of a particular area of practice, and resource constraints.

In some cases, the therapist may find there are laws that serve to direct their decisions in a particular direction. For example, the Human Rights Code in Ontario provides for everyone to be treated equally and without discrimination because of race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, age, marital status, family status, or handicap. These values, which are enacted in law, are obviously an important consideration in the decision making process, yet they will not necessarily lead directly to an answer.

Responses to Practice Scenarios

1. The therapist has initiated service to the client in this scenario, and is therefore bound to follow the rules for discontinuation regardless of the decision to provide further service or not. It is important for therapists to recognize that countertransference (projection of the therapist's emotions on the client) may occur, and by its nature, may improperly influence the therapist's professional judgement if not managed well. It is not a conflict that would necessarily require the therapist to discontinue service, although it is important that it be identified and managed. The therapist needs to determine if she or he requires any resources or support to ensure the integrity of the therapeutic relationship. If the therapist felt unable to resolve this issue and was not able to secure satisfactory assistance, then it may be appropriate to arrange for alternative services for the client.

2. The fact that the therapist is reluctant to say no to this referral suggests that the nature of the relationship is a factor, and may indicate that a conflict of interest exists. The supervisor/staff relationship is one in which there is a power imbalance and thus may influence the therapist's judgement. The therapist is accountable to all clients, and yet she is also required to meet the standards of the profession, which may at times mean that she disagrees with a client's opinion. If disagreement occurs she must be able to express it. In this scenario she should ask herself if she would feel comfortable disagreeing with her supervisor, should the situation arise. An ethical and regulatory dilemma is created and the decision to accept or refuse the referral will require a thoughtful, objective and transparent approach.

3. The therapist has a number of issues to consider. Firstly, therapists working in rural communities where there are limited services may need to consider if they hold increased professional responsibility as a result of their unique situation. Although they are equally free to refuse a referral, they would be well advised to consider if there are alternative services to which they can refer an individual. Otherwise, different methods of providing service to the individuals in their community could be explored (e.g. consultation, assigning and supervision of an unregulated service provider).

This therapist must also consider his or her personal competency to provide the requested service. Although a therapist may choose not to proceed with a referral because of a lack of knowledge, skill, judgement or ability, it is also possible to consider if sufficient resources can be accessed which would then allow the therapist to provide the service. Before refusing this referral, the therapist should also carefully consider if there are additional issues to think about, such as possible discrimination under the Human Rights Code. If her or his reluctance is solely based on the client's particular diagnosis, one might argue the individual's rights are not being respected and the therapist may be opening herself or himself up to a Human Rights complaint.

4. This situation does not appear to involve issues of conflict of interest or personal competency. Nonetheless, the therapist does not wish to accept the referral. Is the fear of being sued an appropriate reason to refuse to accept the client? As stated earlier, the therapist must consider his or her ethical responsibility and needs to utilize a systematic decision-making process that includes consideration of all relevant information before taking any action either way.

Your response to this practice scenario is appreciated. Please contact Susan James, Director of Professional Practice, with your comments or questions: Susan James
(416) 214-1177 or 1-800-890-6570
ext. 233
sjames@coto.org



Resources:
  • College - Guiding Principles of Practice - Section 6 Transparency, 1998
  • College Standards of Practice, 1996
  • College Code of Ethics, 1996
  • College - A Guide to the Health Care Consent and Substitute Decisions Legislation for Occupational Therapists, 1996