High Risk Consent

As you alluded to, one of the fundamental rights patients have is the ability to consent to or withdraw from medical procedures. This is a foundational principle of autonomy, and is governed by Ontario’s Health Care Consent Act (HCCA). The HCCA outlines how informed consent must be obtained, how capacity is assessed, and when others may provide substitute consent if the patient is incapable.

Two key – and often misunderstood – concepts are consent and capacity. They are not interchangeable.

Assessment of decision-making capacity is essential in determining the appropriate course of action when patients refuse treatment or transport, even if they are suspected to have an emergent or life-threatening condition.

Consent is valid when:

• It relates to the proposed treatment;
• It is informed;
• It is given voluntarily; and
• It is not obtained through misrepresentation or fraud.

A person is capable with respect to a treatment if they:

• Understand the information relevant to making the decision; and
• Appreciate the reasonably foreseeable consequences of making or not making the decision.

This creates a nuanced legal and ethical balance between respecting patient autonomy and the duty to
preserve life in emergencies.

With that framework, let’s address your scenario: a STEMI-positive patient who is clearly capable and refuses treatment or transport.

If this patient can demonstrate understanding of their condition and appreciate the risk of death – and still refuses – we must respect that decision, and the refusal of service process should be followed.

Legally and ethically, a capable person has the right to make decisions we may view as unwise or harmful. In such cases, it is essential to document in the ambulance call report the risks of refusal that were discussed with the patient, including the potential risk of death.

In this case, we cannot restrain or treat the patient solely because the outcome could be fatal.

If the patient is not found to have capacity however, an adequate adult SDM with capacity should be sought to the best of a paramedic's ability (ideally a POA if available). They can then either provide consent to the sedation and transport or sign the refusal form on the patient's behalf.

Regarding Section 7 of the HCCA, it preserves the common law duty of a caregiver to restrain someone when immediate action is needed to prevent serious bodily harm – but this applies only when the person lacks capacity in that moment or poses a risk to others. It does not authorize restraint of a capable patient.

Similarly, Section 25 of the HCCA permits treatment without consent only in specific emergencies where the patient is:

• Incapable,
• Facing serious bodily harm or death,
• Has no SDM immediately available, and
• Delay in treatment would worsen the condition.