What is a Medial Directive and how is it delegated?

According to the College of Physicians and Surgeons of Ontario (CPSO) policy on Delegation of Controlled Acts, a medical directive is defined as “written orders by physician(s) to other health care provider(s) that pertain to any patient who meets the criteria set out in the medical directive. When a medical directive calls for acts that need to be delegated, it provides the authority to carry out the treatments, procedures, or other interventions that are specified in the directive, provided that certain conditions and circumstances exist.” 

The Health Profession Regulators of Ontario (HPRO) describes the process of delegation as “a process whereby a regulated health professional authorized to perform a controlled act procedure under a health profession Act confers that authority to someone -regulated or unregulated – who is not so authorized”. 

Many workplaces with occupational health departments utilize medical directives to provide occupational health related services to employees. Examples of these service may include post-exposure prophylaxis, vaccinations, or diagnostic testing. The types of medical directives implemented depends on the unique needs of each individual workplace. The CPSO, College of Nurses of Ontario (CNO) and the HPRO have all provided guidance documents on the development and implementation of Medical Directives. 

What needs to be delegated?

The Regulated Health Professions Act (RHPA) defines several controlled acts, defined as acts which may only be performed by authorized regulated health professionals which require an order to be carried out and would require a medical directive. They can be found in the Appendix section of the CPSO policy. 

However, the HPRO’s Interprofessional Guide on the use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario, indicates that although some acts do not require orders and delegation under the RHPA, authorization may still be required in other pieces of legislation. For example, ordering laboratory testing is not a controlled act under the RHPA, but the Laboratory Specimen and Collection Centre Licensing Act requires that “analysis of laboratory specimens must be ordered by a physician, dentist, or as permitted by regulation a midwife or a nurse in the extended class”. 

When and how to delegate? 

The CPSO sets out expectations for physicians as authorizers for medical directives. The policy outlines that delegation of controlled acts is permitted “when doing so is in the best interest of the patient”, physicians are to “only delegate the performance of controlled acts that they can personally perform competently”, and when the following conditions are met:

1. the patient’s health and/or safety will not be put at risk;
2. the patient’s quality of care will not be compromised by the delegation; and
3. delegating serves at least one of the following purposes:
   1. promotes patient safety,
   2. facilitates access to care where there is a need,
   3. results in more timely or efficient delivery of health care, or
   4. contributes to optimal use of health­care resources.

The CPSO expects the following information to be included in the medical directive:

1. The name and a description of the procedure, treat­ment, or intervention being ordered;
2. An itemized and detailed list of the specific clinical conditions that the patient must meet before the directive can be implemented;
3. An itemized and detailed list of any situational circum­stances that must exist before the directive can be implemented;
4. A comprehensive list of contraindications to implemen­tation of the directive;
5. Identification of the individuals authorized to imple­ment the directive; 
6. A description of the procedure, treat­ment, or intervention itself that provides sufficient detail to ensure that the individual implementing the directive can do so safely and appropriately; 
7. The name and signature of the physician(s) authorizing and responsible for the directive and the date it becomes effective; and
8. A list of the administrative approvals that were provided to the directive, including the dates and each committee (if any).

The policy further sets out the expectations for delegates, specifically that the delegates “have the knowledge, skill and judgement to perform the delegated acts competently and safely”, and they are “able to accept the delegation”. Supervision and support for the delegates that is proportionate to the risk associated with the delegation is expected, and the delegation process need to undergo ongoing monitoring and evaluation. 

The HPRO specifies that “sub-delegation – delegating a controlled act procedure that someone is authorized to perform by way of delegation to someone else – is not permitted”.

The CNO Practice Guideline on Directives strongly recommends the development of medical directive involve all health care professionals affected directly or indirectly by the directive. The CNO further dictates that policies need to be in place before a directive is adopted as a method for providing healthcare. The policies should identify the types of procedure that may be ordered by means of a directive, determination of the involvement of the directive authorizer, identification of who may implement a directive etc. 

The CNO describes that, with respect to implementing the medical directives, the delegate is responsible for:

• Clarifying that informed consent has been obtained
• Assessing the client to determine whether the specific client conditions and any situational circumstances identified in the directive have been met
• Knowing the risks to the client of implementing the directive
• Possessing the knowledge, skill and judgement required to implement the directive safely
• Knowing the predictability of the outcomes of the intervention
• Determining whether management of the possible outcomes is within the scope of her/his practice; if so, whether she/he is competent to provide such management and if not, whether the appropriate resources are available to assist as required;
• Knowing how to contact the authorization responsible for care of the client if orders require clarification

Each workplace is unique and may require a combination of different medical directives to meet the needs of the workers. Occupational health departments can use regulatory bodies policies and guidelines to help better understand the regulatory requirements for the development, implementation, assessment, and evaluation of medical directives.