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Obtaining informed consent for an incapable client when an SDM is not available

Obtaining informed consent for an incapable client when an SDM is not available


Lily, an occupational therapist (OT), was notified by staff at a group home that her client, Davon required a new wheelchair cushion. The cushion had a leak and was putting the client at risk for skin breakdown. Lily went to the group home to see her client and reassess him for a new wheelchair cushion.

While reassessing Davon at the group home, Lily realized that his cognition had declined since her last visit and he no longer had the capacity to consent to the proposed occupational therapy treatment. Lily discussed this with the group home staff, who had also noted a recent change in Davon’s cognition. Through further discussion with the staff, Lily determined that Davon’s only remaining family member, his dad, had recently passed away leaving no one available to act as a substitute decision maker (SDM).

Lily decided to contact the Office of the Public Guardian and Trustee (OPGT). She explained that she needed to obtain informed consent for her proposed treatment. She was told by the OPGT staff that it may take some time to obtain informed consent as it involved a process of starting a file for the client, examining the process used to deem the client incapable, and examining the treatment being proposed. Lily was informed by the OPGT that if the treatment she was proposing constituted minimal to no risk, she could use her judgement and determine if she should proceed without obtaining informed consent.

Lily was aware of the expectations to obtain informed consent for her occupational therapy treatment according to the Standards for Consent, however, waiting for the group home to locate another possible SDM or waiting for the OPGT to provide consent could put Davon at risk of skin breakdown. Lily considered her options.


  • Using the Conscious Decision-Making Framework, Lily identified all potential options.
  • Lily examined the level of risk of her proposed occupational therapy treatment.
  • Lily examined the level of risk to the client if she did not provide the occupational therapy treatment.
  • Lily reviewed the Standards for Consent and the Health Care Consent Act, 1996.
  • Lily called the Practice Resource Service at the College.


  • Lily worked through the Conscious Decision-Making Framework. She decided her occupational therapy treatment involved minimal risk and determined that the risks to Davon of not providing the treatment were greater than the risks of providing treatment without obtaining consent. Lily decided to proceed with obtaining a new wheelchair cushion for Davon.
  • Lily documented her decision-making and clinical reasoning in Davon’s record. She explained her rationale for deviating from the Standards for Consent.
  • Lily worked with group home staff to start a file with the OPGT to ensure informed consent could be obtained for future treatments.


OTs are expected to follow the College Standards and Guidelines. In circumstances such as those outlined in this case, the College expects OTs to use their clinical judgement to make decisions that do not compromise client care or put clients at risk. OTs are expected to provide reasonable rationale for any variations from the Standards and document that information in the clinical record.



If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or [email protected]

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