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Toronto Star: The use of anti-psychotic drugs in long term care homes: what does this issue tell us about informed consent?

The Toronto’s Star’s coverage of the use of anti-psychotic pharmaceuticals paints a grim picture of the treatment of older adults in long term care who suffer from dementia. It also raises questions about two related issues that we have explored previously in this blog:

  • Behavioural Supports Ontario (“BSO”)
  • The importance of informed consent

The comments made during Ontario Health Minister Deb Matthews during a scrum at Queen’s park on April 15, 2014, suggest that that the BSO and the issue of informed consent both play integral roles in the use of anti-psychotic pharmaceuticals in long term care.

Minister Matthews suggested that the BSO program is an alternative to the use of anti-psychotic drugs to control aggressive behaviour. The Star reports that government has invested 43 million in the program. What is not clear in the Star’s report or in Minister Mathews’ comments is how effectively that money is translated into BSO staff in long term care homes. You can read more about this program here.

With respect to informed consent, the Star reports that Minister Matthews stated that “it is clear to her that “doctors cannot prescribe this kind of medication without the consent of the individual or their substitute decision maker.””

Unfortunately, we do not share Minister Matthews’ confidence in this regard. As we’ve written previously, the Law Commission of Ontario commissioned a paper on this subject, and it was determined that healthcare practitioners in Ontario are relying on advance health care directives rather than seeking informed consent of a patient or his/her attorney for personal care, as required by law. It is not clear to us, based on the LCO report, that doctors prescribing anti-psychotics are necessarily obtaining informed consent.

The Star reports the following:

  • a 2007 auditor general report warned the government about the overuse of antipsychotic drugs;
  • the drugs at issue are not approved by Health Canada for elderly people with dementia. Pharmaceutical companies have issued the strongest possible caution, known as a black-box warning, on their labelling. A typical warning says:

“Elderly patients with dementia treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo”

  • In one of the cases probed by the Star, antipsychotic medication was apparently given to a senior without consent.

Given what we know about the inconsistent approaches to obtaining informed consent, when we consider the facts presented by the Star, it seems unlikely that older adults or their substitute decision makers are providing consent that is truly informed at such a rate that “roughly half” of the residents in more than 40 homes across the province are currently taking these risky medications.

Many of our clients who act as Attorneys for Personal Care have reported to us their concerns that their older loved one appears to be overly, and perhaps unnecessarily, medicated.  It is not always clear that substitute decision makers are informed about the effects of these drugs, and it is difficult to identify which behaviours are likely to trigger the use of these drugs.

This issue would benefit from further investigation. As suggested by the LCO paper, a coordinated effort to educate frontline health care workers, doctors, and substitute decision makers on the nature and process of informed consent would benefit everyone involved in the provision of care to older adults.


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