Standardizing Substitute Decision-Making Identification & Documentation in Critical and Acute Care
CCCF ePoster library. Abdool R. 11/12/19; 283400; EP58 Disclosure(s): I have no disclosures to declare.
Rosalind Abdool
Rosalind Abdool
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Topic: Quality Assurance & Improvement

Abdool, Rosalind PhD1,2,3,4; Godkin, Dianne PhD1,3,5,6,7; Variath, Caroline RN MN PhD(s) 3,6,8,9 ; Kennedy, Carlijn MSW RSW 10
1 Regional Ethics Program, Trillium Health Partners, Mississauga, Canada; 2 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; 3 Joint Centre for Bioethics, University of Toronto, Toronto, Canada; 4 Canadian Association for Practicing Healthcare Ethicists (CAPHE-ACESS), Toronto, Canada; 5 Institute for Better Health, Mississauga, Canada; 6 Faculty of Nursing, University of Toronto, Toronto, Canada; 7 Canadian Bioethics Society, Ottawa, Canada; 8 School of Health Sciences, Humber College, Toronto, Canada; 9 Cardio-Surgical Intensive Care Unit, Trillium Health Partners, Mississauga, Canada; 10 Operations, Flow & Patient Registration, Trillium Health Partners, Mississauga, Canada

Taking direction from the wrong substitute decision maker (SDM) is a type of error that may occur in health care. Errors of this type are legally problematic – insofar as they can result in violations of the Health Care Consent Act - and ethically problematic – insofar as they can result in decisions that are contrary to the previously stated capable wishes of the patient. Currently, we lack good evidence concerning the incidence of SDM related errors in Canada. In an effort to decrease the incidence of these errors, a substitute decision maker form was developed to be completed for all patients upon admission.
The overarching goal of this project was to optimize the identification and documentation of SDMs. As a step towards achieving this goal, an SDM form was developed and piloted on the cardiac surgery unit at THP. The cardiac surgery unit included the cardiac-surgical intensive care unit and the cardiovascular unit. These units admit patients following high-risk interventions and procedures, which often involve a time period where patients are unable to make decisions for themselves and may require an SDM.

The new SDM process involved a range of interventions, including staff education, the new SDM form to be placed in the patient's chart, and changes to nursing intake. To evaluate the impact of the SDM form, the following assessments were undertaken 1) baseline rate of SDM identification and documentation on the pilot unit prior to the implementation of the SDM form; 2) rate of SDM identification and documentation on the pilot unit following implementation (through chart audits); and 3) rate of SDM identification and documentation at three months and one year following implementation (through chart reviews). 
Baseline documentation of SDMs was 14%; post implementation this increased to 42% 1 year after the form was introduced. There were 11 different locations noted where staff and physicians looked for information about SDMs at baseline; this decreased to 7 locations post implementation, with 27% now identifying the form in the purple chart as one the locations. There was a decrease in the percentage of staff who were looking for SDM information in Sunrise Clinical Manager or Meditech. Another result is that the staff are using fewer locations to document SDM information with the implementation of the form and education - 12 locations were identified at the baseline survey; post implementation, this was reduced to 7 locations. There is room for improvement, but the results are moving towards greater standardization. Staff previously had 18 different alternatives for updating the information, whereas now they only utilize 10, with the majority of cases involving staff feeling comfortable to update the information themselves on the SDM form. The SDM form serves as a reminder that it is a legal, ethical and professional obligation to get consent from the correct SDM(s) when patients are incapable.

  1. The implementation of an SDM documentation form successfully increased the documentation from 14 to 46% - a 32% increase.
  2. Staff benefit from regular reminders (e.g., by using the form, at huddles) to request supporting documentation for powers of attorney for personal care.
  3. Identifying champions (e.g., social workers, clinical educators) helped to motivate and sustain change.


“Health and Social Services Standards” Accreditation Canada. Accessed June 23rd 2019.
Foreman, Thomas C., Dorothyann Curran, Joshua T. Landry and Michael A. Kekewich, “Documentation of Capacity and Identification of Substitute Decision-makers in Ontario,” Cambridge Quarterly of Healthcare Ethics,23(2014):334 – 340.
Glezer, Anna, Theodore A. Stern, Elizabeth A. Mort, Susan Atamian, Joshua L. Abrams, and Rebecca Weintraub Brendel, “Documentation of Decision-Making Capacity, Informed Consent, and Health Care Proxies: A Study of Surrogate Consent,” PsychosomaticsNo. 52 (2011): 521–529.

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