Event ID: 2351884Event Started: 8/6/2014 10:21:04 AM ET

Please stand by for realtime captions.

Good morning and thank you for joining us. This is Lori with UNTY an today's webinar is the second part of our webinar series on Informed Choice: It's a Matter of Ethics and talking about making choices is an important part of gaining independence at achieving employment success. Again we have Dr. Chandra Donal with us to make sure that we have everybody on board and being able to hear us, I see that she looked you have already sent a note, if you could go down to the question box everyone in the control panel and send me a note if you can hear my voice okay so that everything is loud and clear on your end. So just send me a yes or Howdy. Hi Rosa, thank you so much. Margaret, José, Barbara, Catherine, Dan, Anthony, awesome. Debbie as well. And just as a reminder if you have any questions or comments for our speaker today you can use the question box to give those comments and we will certainly share them with the rest of the audience.

If you're on the phone only and not using your computer [ Indiscernible-distorted audio ] send an e-mail to join us while we are in session. I will be back with you later towards the end of the session, the session is over at 10:30 AM, to give you a few more ideas of what is going to happen in regards to getting credit for your presence today on this webinar. Without further ado I want to introduce Dr. Donal again who is a professor at Rehabilitation got counseling at UNC and is lots of work experience in counseling and therapy and she gave us a wonderful introduction to the concepts and ethics during last session, and today she will either through some case studies. To take it away.

Good morning everyone and thank you all for joining us again. I know last week we went over a lot of information and I just wanted to make sure that as you have questions you do feel free to use the question box and hopefully I can respond to those as we move along. Our focus for today will still be on looking at informed consent. But we're going to look a little bit more at some case studies that applied. I cannot remember exactly who was last week was one asked a great question about individuals who may have some sort of cognitive impairment. Based on that and some additional research I did, just think about areas where people are mostly challenged in regards to informed consent aside from the time management challenge and we will talk more about that today.

I decided to focus on the case for Web and individual who has a psychiatric disability and also transitioning minor. The minor is individual is one of the more challenging cases to deal with. Just as a review here are golden 5+ one of our ethical principles that kind of got all of our work and our embedded deeply into the ethical standards. In regard to informed consent it is important to remember that it has a foundation in making sure that we support client and consumer autonomy.

And really focusing on beneficence and making sure that we're working toward their well-being and looking at Fidelity making your list of commitments and making promises so the information set forth in our informed consent form that we verbally discussed with them, it is

important to maintain that. It is our agreement or document with the client or consumer groups and also veracity to make sure that we are being truthful and dealing honestly with our clients. All of our consumers and clients are coming to us for assistance and so our wallets helpers is to make sure that we do so or that we do so in a more objective and most honest way possible so they have the full information about what they might experience so they can make informed choices, and maintain autonomy throughout the process.

The next couple of slides are also review from last week in a religious cover what should be included in informed consent. One additional piece I'll add to this, I will not go over these agree to you tell again, but I do want to make sure that you understand informed consent can be a recurring process. Just simply because of the treatment plan, the intervention or the services might be altered based on assessment results, how well a client or consumer is doing in their current service or the treatment they are in. There are different things a client may need to come out of treatment services for point in time to go for hospitalization or something to that effect. It is not something we should visit just once in the process. It can be re-occurring and that is important that we do that just to remind the client and consumers about what we are focusing on and so that they are able to react to make choices they still missed changing needs.

The next two slides go over all the different types of things that are typically included in informed consent. There was a question last week that focused a little bit on some or a comment, that focused on the time that it takes. In informed consent because we are handling so many different anxiety the time but we are working with our clients and consumers, and we have limited time, just working the issues with them, all these different components seems like it might not be achievable.

When these services are mentioned or the aspects of informed consent are discussed each and every single one of them may not need to be reiterated as the same level of another. Talk a lot lasted about confidentiality and the limits on that and we definitely want to talk specifically about that in addition to what the client is using to sign off on as confirming their understanding of it. We want to spend time on our duty to warn and what it looks like for agency in our state and want to talk about what our role is in with the client or consumer's role is in this relationship.

We want to spend a little bit of time regarding our role if we have any in determining eligibility and in fits and want to make sure that if there's a separate form for HIPAA that we talk specifically about HIPAA in their rights to review the records and what that tells and then talk about what will happen as a result of their treatment, the positive in the narrative. They can use that information to make the best decision on how they want to move forward and that includes themselves or their legally authorized representative.

The last thing we always want to make sure that we carefully states our clients and consumers is to make sure that we give them specific information about it is their appeal rights within the agency. So if they find that for whatever reason they are not satisfied with the services or they have questions, that they do have the right to seek assistance from someone other than their counselor or service provider so they can have those questions or concerns remedied.

What I want to focus on today, and the two cases that I have really do harken back to the concept of capacity for informed consent. As you remember from last week we talk a lot about capacity

kind of being the terminology to determine whether or not a person is able to make informed decisions. What their ability to understand is, the information that they are relating to them and to know they have the ability to voluntarily consent and that they understand that they can also withdraw services at any point in time.

If they choose to withdraw, spinning, nature of the person that you are seeing, they need to know clearly what the consequences of the withdrawal might be. They may know longer want the services and that might mean they cannot work with the vendors providing job development services and we could no longer provide oversight for any other types of services, whatever the case is, what's make sure that as they know they have the ability to withdraw that they also understand the consequences. The whole point of this again is to make sure that they are fully aware of what their rights are in the process.

Here is the case study and this is a case that focuses on a case with minors and I tried to make a very general so that might apply across the board with a very serious you guys are working in. There is a 14-year-old that walked up to therapist who is a transition counselor at his high school, there is many personal family problems, extreme difficulties physically and attention in the classroom which includes some comments about some physical abuse is receiving at home. The client asked the therapist not to discuss this with anyone especially his parents. The therapist explained his options to the client states he cannot offer treatment to anyone under the age of 18 without parental consent and also expresses his duty to report suspected child abuse to child protective services. After hearing the information the client and feels betrayed.

The situation for this is actually one that I am familiar with from a person I worked with before, they were a transition counselor at a school and this was a student who had been assessed for ADHD but I was not sure of the actual diagnosis that come in yet, and decided to seek out this individual because they knew they help other students with disabilities and during that drop-in visit the student went over everything they were experiencing, and during that reticular session or meeting time talk about some abuse that the child was experiencing at home.

At that point because this person was not an actual client for the therapist, they had not gone over all the different information and informed components. And at the end indicated they could not work with anyone under the age of 18 without consent that they did have a duty to report. Here are some questions I would love for us to ponder a bit and to take time to think for this situation and what we know about informed consent to see whether or not there is an ethical issue that exists here. If there is, what principles are at play? And if you do feel like the therapist could've done anything differently what would that have been?

Chandra do what some people are going to make comments and the question box or go ahead and here response to any of the questions?

That would be great.

The therapist should have given the child the information regarding the services before he was allowed to discuss the personal issues. [ Indiscernible-low volume ] so that was a different way to approach it.

I have not received any other comments at this point.

Let's just go over that. Certainly the therapist had a right, and should have disclosed the full information. The challenge here in the ethical issue that exists here is that some individual feels like the person was not exactly the client of the therapist and so the therapist did not legally have to go through informed consent procedures because of this drop-in student. However, on the other side of that, if you think about your role in during the school system in your seen as a provider of services, within that role you deaf I have the duty to warn city that the student I come in during your drop-in hours the very first thing you should go over, and Medra is absolutely correct, is talking about some of the rules surrounding informed consent, particularly when dealing with minors. The method of you have been around kids are teenagers, I have a 13-year-old niece in the first issue always says is due not so my mom. So I have a little more flexibility in interpreting what I do with that as a professional we know that is how teenagers operate, they're coming to confide in us for various reasons of this particular client felt as though there was not a safe home environment to talk to some of these issues.

That as professionals we know that if a minor is seeking services and they are going to speak with us the very first thing you want to let them know is one, we cannot provide actual treatment to them without parental consent, and number two, if in the process of talking with them that we hear anything that falls underneath our duty to warn requirements than as an agent of the state, you are required to warn and provide notice to the appropriate authorities.

The concern that some people have is that will shut the person down, they will not want to talk in me or confide in me but I don't know if that is always the case. I think yes& Like it happened, but depending upon how you preface it, depending on how you are able to speak with the client and relay some of the reasons as to why it is necessary, then I think those clients who are in the situation where they really need to share information or they are seeking help without knowing that is exactly what they are doing, and you still can have a beneficial relationship with them. So she is absolutely correct, the therapist in this particular situation should happen for the client started to speak kind of briefly going over here are some things wait to be mindful of that I have to honor for my own ethical code as an agent of the state to make sure that everyone is protected in the process.

We did get a couple of additional comments, one is from Mark I would have little more time because he said he cannot type fast enough. The simple solution would have been to review the information ahead of the conversation. And also from Freda, consumer provided info before informed consent was given in the referral was given an order for the school counselor [ Indiscernible-low volume ] . Appreciate this interaction.

Great. For the next case we can definitely slow down a little bit so you guys can get some additional information I get some time to type things out. I want to refer back to the comment Freda made about the student confiding prior to consent being given in the referral being required. For this particular student in this particular situation or have someone who is there in the role of transitional counselor and certainly any of you all who love working transition services no yes your main goal is to focus on aspects of transition was mandated by the law and what is required by the school in order to help the person move through the process. However we

also know that in any situation we are working with a client or consumer, they inevitably personalize and their situation comes into the picture.

There are times where that type of information also that our scope of practice to address in their times and that type of information falls outside of our scope of practice. If you think back to a couple of slides previously we were talking about informed consent one of those was to talk about what the counselor's role is that it is not only to relate to our clients to make sure that we understand what our role is as a professional in a particular setting. Informed consent having been talked about, the person has given you this information and because the KB's information prior to you receiving informed consent now you want to refer the client on any matter for the months of psychotherapy which I think is a creep -- completely appropriate. However the lingering question for you is a practitioner, and maybe this is the question we should consider as well, you know how this information regarding this particular client and so what do you do with it? Let me know what you guys think.

Call CPS.

[ laughter ]

Yeah.

[ Silence ]

And there is a duty to report.

Okay. I see that there are some of you guys that are out there and really weighing the ethical consequences on what the duties are and I those would definitely be appropriate responses. You start receiving permission as an agent of the state and as someone who is interacting with minors you do have a duty to report information and as I mentioned before, in the state of Texas, in regards to how your duty to warn a third-party, there is not as much protection just because of the state of Texas statute and how they interpreted as federal law. However when it comes to minors, there is a lot more minor and vulnerable populations there is more protection in place for practitioners which is to report.

One of the things I think that is really important also is that now that you've mentioned to the client at the very and this is something that you will have to report in the client feels betrayed, I think it is important that in order to maintain a relationship that will allow the client, I don't know if the word willingly is a good phrase or not, but to willingly going to therapy with another person that feeling as though the entire therapeutic process is against them. It is to say I understand that you are upset and I understand that you are concerned but this is what my responsibility and duty is as an agent of the state and as an employee of the school system, so on and so forth. And it is in your best interest as we investigate was on in your own. I'll transfer you to another counselor and I went to take care of what my duties are in regards to my position and don't make sure that the other counselor has the information they need to move forward with you and they can talk with you more specifically about what your rights are and what their duties are so you have a better understanding as we move forward with the next person.

Anytime that we have to report it is important for us to make sure that we relay that information to the client to protect their rights, but it also yields back a little bit to the comp -- concept of beneficence. Because if we are working with someone who is a vulnerable adult who is in an abusive situation or a minor in an abusive situation and a report is filed, happens after the report is filed as a little bit of our concern as well so we want to make sure that the person has noticed that it report will be filed says they're working with the next practitioner they can make arrangements they need to maintain their safety in a situation where we are unsure what the safety may look like for the.

We did receive a couple of additional comments and one says there are guidelines for steps to take in this situation then you must follow and report. And the other comment says he should call the parents to let them know.

Okay. The statutes are murky on this, in a situation where safety is a concern, the first reporting may not go back to the individual with which the report has been made against. In this situation, yes, you cannot provide treatment to the client because they need parental consent because they are specifically underage about is very clear in the statute. So as they are transferred in refer to this next therapist that person will need to receive rental consent to treat individual for whatever reason they designate. They could designate that they want to work with him on his issues in school and help with his hyperactivity and they could talk little bit about issues he had been having in the classroom, whatever they feel comp to bowl with seeking consent from the parents to treat individual they can because the therapist also hasn't heard the same information you have heard, so they do not have a need and they are not required to say I want to work with this particular student because they said that they were experiencing sexual abuse in the home.

The duty of the statute is presented and that is as the report estimates the appropriate authorities and those authorities will then make contact with the family system which will alert the family system of report has been filed. In most cases the nature of the report of the origins of those reports are not revealed because the particular agency has to go through their investigative process. But that does very depending upon the nature of the situation and how agencies handle reporting practices. Generally speaking the reporting agency or I'm sorry, the agency was going to conduct the investigation is the agency will notify the home system or family system the report has been made and they will conduct an investigation from that point forward. Thank you guys for your comments.

We did receive one additional story or question. So if after you go through your second example and if we have time that would be something that we can maybe pick up.

Thank you. Our next case study is focusing a little bit on consent given by someone who is perceived as having an impairment, in this situation a psychiatric impairment. Nancy had a history of paranoid schizophrenia and many omissions to the state hospital. At the time of the emotional stability she completed an exam directive. Durable power of attorney designed to designate a substitute and she then became psychotic and was able -- unable to make particular decisions. During that she decided to reject any and all antipsychotic psychotropic or psychoactive medication. So in her durable power of attorney her advanced directive, or request based on her right was to decline medication. She is now seeking employment as she is not hospitalized, however, she is demonstrating some symptomology. But she maintains she will not

take any medication to address the manifestation of her symptoms. You are the individual that she is seeing to help her gain employment and be productively employed. Here again we have to kind of look at what is your responsibility in regards to your work with her?

When you're working with individuals with psychiatric disabilities and the medicinal compliance is often an issue that is discussed in the process. It goes to the concept of disclosure and how an individual wants to talk about talk with others regarding their diagnoses. So here again, what is your responsibility in finding her employment knowing that she is refusing to take medication? Is there an ethical issue here at all and if so, what ethical principles are at play? And how might you address the issue through the process of informed consent? You can respond to any of those particular questions.

One question they came through was to explain the durable power of attorney. Is it a specific arson -- is it a specific person?

Yes. This is a person who would have to individuals or one individual with control over medical decisions as well as decisions over legal matters that might come up with individual. So it could be a designee such as a spouse or a child, I actually had durable power of attorney at one point with my father who had experienced a series of strokes and had cognitive impairment from that and my sister and I shared durable power of attorney.

[ Silence ]

The next question is what does the power of attorney have the power to do in regards to the person taking the medication? The next question would be in regards to their vocational rehabilitation plan.

The durable power of attorney has the ability to make hospitalization commitments, but they do not have the ability to force medication. That is the express right of the individual is whether or not they want to take medications. If she isn't voluntarily committed she will not take any medication, and even in the absence her designee would not be able to say that she has to take her medication, the hospital would not make provision to say yes give her the medication. And as you think about this, just this particular case, I did alter slightly to fit the concept we're talking about. This is a very interesting case they saw actual case law here in 1998 Nancy Hargrove and actual individual the state of Vermont presented this advanced directive through her durable power of attorney, and the state legislature at the same time had passed and act allowing hospitals and hospital personnel to seek out competency hearings for involuntarily committed patients to say that if they are involuntarily committed they are not competent they cannot make decisions about whether or not they can accept medications or not that would bring emotional and psychological stability.

Nancy argued that the law of Vermont actually violated her rights under the Americans with disabilities act and in this particular case went through the several different levels of appeals. The second circuit Court of Appeals agreed with her rather than the state that the state did not have the power to deem her and competent since her advanced direct was put into place during the time where she had noted emotional stability and could not force her to take medication. This is something that came across in 1998 and the Vermont state legislature.

So the really interesting case about patient's rights, I related it back to the informed consent for our purposes, but it does focus on the aspect of autonomy and what responsibilities are in regards to honoring autonomy.

A couple of other comments says that durable power of attorney does not apply for employment purposes, disclosure is not appropriate. Is going to be tough going for the job search and it may not be employment ready.

The comment in regards to durable power of attorney and employment is exactly right. Durable power of attorney will do situations of all hospitalizations and taking care of finances when the person does not have the capacity to do it at the particular time that they may need to be hospitalized or seek additional services. But in regards to employment, this kind of brings us back to our thinking about the person comprehensively and holistically in understanding the right. The durable power of attorney does not have a role in that and if Ms. Hargrave has decided she will not take dedication while she is in the process of employment, it does boil down to the therapist and counselor really thinking about what she is seeking employment and what type of employment might be available for her and whether or not she is ready to go into that. And not necessarily ready such as having the capacity to perform, but will her symptomology cause her and the stress of work, additional setbacks in the overall recovery process? And that goes back to the concept of beneficence negation we are working to the benefit of the client and their well-being in what we do.

But it is important in regards to consent that we articulate our thought process to the client as we are working with them. If you remember some of the concepts included in the informed consent, a couple of them talked about making sure that the client knew about the negatives and positives on the impact of the treatment and that they also knew about some of the disclosure and in this case non-medicinal compliance. It is important for them to know that while they might be feeling fine or functioning fine, that there might be certain triggers or stressors in the workplace it could exacerbate their symptoms and it may cause them to not be able to balance as well as our right now with the appropriate process looks like.

That is an important conversation to have with them and it is our responsibility to make sure that we fully disclose what we know about the workplace, the world of work and the culture of work and stresses associated with her condition so the client can continue to make a decision that might work in their best interest. For the person who said it would be difficult but is probably very true. It will be very difficult to find a position for her to work and be successful in all shoes trying to manage and balance.

Transition employment opportunities [ Indiscernible-low volume ] . A couple of other comments, I would think that would be the counselor's role to get the authorized person involved. I hope I got that right. I would think that would be the counselor's role to get the authorized person involved. I'm not sure if there are any other comments on that one. And also there is added in this scenario, in the interest of the potential employer overshadowed by the client's preferences question mark

Could you read that again please question mark

I hope I'm reading it correctly, in this scenario are the interests of the potential employer [ Indiscernible ] to the client's preferences?

That is a fantastic question. And here is the rub. As a person working with vocational rehabilitation with the constantly question who is our client and where are our alliances? We know that our code of ethics specifically designates that a person with a disability is our core focus of the client of interest the main person we're focusing on. But we also have to be very mindful of the relationship we are building with our employers in the business world. It has employment for persons with disabilities, particularly when talking about psychiatric disabilities, whether such a negative attitude surrounding it, if we play someone in an employment situation who has decided not to take the medication, and whatever other treatment they've been participating in, he might be just baiting and wellness recovery action plan or some other type of treatment modality psychotherapy, if we put them in that setting they are not able to balance its and it causes issues in the workplace, that fractures our relationship with the employer. But the question is what is our responsibility?

One, we cannot legally disclose the disability to the employer without the individual's consent, that is very clear. There really is no question around that, however, this might be a place where we might want to seek consent from the client to say I respect your decision to not take medication that my experience also tells me it is sometimes difficult to manage and balance symptomology at the same time you're trying to balance and manage a new workplace and work culture and so on and so forth. Would it be acceptable for me to talk with the supervisor regarding your general psychiatric needs so that we can work to make accommodations and have natural supports put into place and other supported features that would help you to be more successful on this journey? That is the consent you need to receive from the individual.

And how you talk to the employer is important as well. There was a time when people were working with the patient in rehab really did try to rely on the goodwill of employers to hire individuals with disabilities. We are no longer in that timeframe. Another persons with disabilities are competent and excellent workers and can provide the same level of service with their peels without disabilities when the appropriate supports are in place. Want to make sure that we cautiously and in a measured way to the employer regarding the disability after they receive consent and if only we receive consent from the individual, to make sure that we can focus on building some natural supports in that environment that might be assistive to her and I employment process. So we do have due diligence to the employer but we also have due diligence to our clients. Our due diligence for the employer that will depend upon the nature of our relationship with the client and with the client allows.

We might also think of, and the whole repertoire of employers we worked with before him a Lisbon must open working with our clients or consumers with psychiatric disabilities and what types of environment seems to work well with the various clients we've worked with in the past? To make of their initially where it may not even be necessary to focus on the disclosure aspect, the environment itself might be supported to the individual in the managing of their symptomology. That is another resource for us to use, looking at past contacts in looking at what situations have worked well. [ Indiscernible-low volume ]

Another comment we received is I would consider telling her that when she is stable on her meds again that we can continue the job search, that that I am unwilling to work on that with her until that time.

And during the consent process that is something that you can talk about in regards to the possible negatives and how the person is moving forward in regards to treatment. Most agencies, but may not say that, if there is not a requirement for demonstrated medical compliance, then that is something that you individually to making a decision on. For that I would refer you back to the ethical principles embedded. You really have to examine are there any ethical issues with you making a decision to not work with the client based on this feature? Will be the impact on the client or consumer and what will be the impact on you as a professional? These are the types of questions you want to ask yourself we make those decisions that are not a part of agency policy or state statute or law so that you can make sure that you are still being guided by the ethical principles. Our code in general, and I do not have in front of me right now, does say we are not allowed to refuse treatment based on cultural dimensions.

Someone who is not medically compliant would be a challenging client, it is also a cultural condition and it is actually looking at whether or not they are meeting agency policy or state statute or law. So as we make these decisions we really have to go back to our principles and preferred our code to get a sense of what our responsibilities are to the client, how we are best protecting their rights and thus protecting ourselves and our scope of practice.

Our code of ethics, and this is just an FYI for you guys if you don't know, the CRC see commission does have a place where you can anonymously submit questions regarding ethical questions were dilemmas. There is an advisory board to review these questions they will submit a response back to you through the responses they submit will not say you should do this or do that, it will refer you to the code of ethics and various standards within the code it gives you more specific guidance on whether or not a certain practice or decision to be in violation of the code.

That is a key component of the ethical decision-making process is as you're thinking about whether or not what you were doing as a dilemma that exists, you support the client even though they might not be successful or they are extremely challenging him you should seek consultation from a peer or supervisor or you could certainly think about the pros and cons with either decision that you make in regards to how you work with or if you do not work with the client. And you can seek out feedback from our commission to give you some direction, well, not direction but guidance, within the code on best behaviors.

[ Silence ]

[ Indiscernible-low volume ]

We're winding down a little bit on time and I know we have another case question out there. Let me go through our next couple of sizable, to the case question and we can wrap up with that particular one.

Okay.

These are our informed consent best actresses of this is put forth the alliance for healthcare research and quality so it really focuses on quality research and healthcare practices and they talk a lot about informed consent. One of the things I think is important for us as we think about informed consent is a plan for potential science that may have limited proficiency. This is important to consider, particularly in the state that we are in where we do have a number of clients who have come through from various backgrounds who might not have the same level of English proficiency as we do or as what we present to them. It is important for us to think about how we engage that individual talking about informed consent and whether or not a need for an interpreter for the individual is needed and whether or not we need to use different consent forms that would have language more clear and more plain language.

What you typically see in informed consent forms, these are all things we think about ahead of time to meet this particular population needs. It is interesting when you talk about limited English proficiency and you talk about this cultural concept, the push for informed consent was actually born from the infamous [ Indiscernible ] project and I'm not sure if you guys are familiar with that or not, from about 1932 up to 1947, the health commission, I cannot member the name of it at the time, but it is department of Health and Human Services today, that same bridge of the government conducted studies on American citizens who were predominantly African-American men where the premise of the study, the actual premise, was to look at the impact of untreated syphilis.

However, the process of recruiting individuals to participate in the study the researchers did not fully disclose what the premise of the study was. They told individual that they were doing work to look at a population of persons who had bad luck which would include anemia, -- bad blood, anemia, syphilis or any other blood disease, at that time. In the actual study there were individuals who participated in the study who had syphilis. There were about 600 people in total that had syphilis and the individuals who had syphilis were given placebos because the scientists really want to see what it looked like and as a result of that the participants condition worsened in some participants past. Even one penicillin came out as the noted treatment for syphilis the individuals in the study still were not given a medication.

Was this was revealed him a and I think it was decades later maybe around 1973, and the visuals from the study who were still remaining sued the federal government, and that actual experiment or study was one of the things that really spawned institutional review boards and internal review boards to look at research methods, and it is really where informed consent is a concept was born out of in regards to individual participation in treatment and research services. It is important for us as we think about what informed consent is understandable but of the history of it is to understand and know that there are cultural adaptations that need to be made as we are working with individuals who have limited English proficiency or who have linguistic differences. Those individuals who are from areas where their definitions of disability and their definitions of rights are different because of maybe their country of origin or nature -- ordination of origin.

And it is important for us to have this considerations in mind as we are working with our clients and consumers. One way to address that is to offer to read the documents to all of our clients and servers to of course some will say no, I understand it so that's okay. And that's perfectly acceptable. But for people who have limited English proficiency or cognitive impairment or may

have distorted conditions due to psychiatric impairment, it is important that we have the explanation of the document. We want to make sure that we document that the informed consent has been disclosed. We're just using the forum as a place for them to sign off on that clearly Dick Cates what we are talking to them about so that we can know that the person's consent was actually received. And I think I mentioned this during the last session, as you are discussing informed consent there is the written form but there is also the need for the verbal conversation with the individuals.

Similar to what would just learned during our session, needs to give the client or consumer adequate time so they can read the documents themselves, and adequate time if we choose to verbally talk with them about it. I had a student once many years ago those originally from South Korea, he was an advisee of mine and he talked to me, we were talking in class about why he is so quiet in class. I was assuming there were cultural dimensions there from not speaking in the American peers, it was culturally related but different from the thought. The thought processes he hears what's the question is and he translates it into his native language so he can understand it and he comes up with a response is negative or native language. Then he has to translate that and that he is ready to speak and by the time he is ready to speak and after he goes to the cognitive process someone else's answer to question and we move on. It is really important, and that was eye-opening for me. It is important to allow time for the individuals to process what we are talking about its process with their reading.

Discuss the final point for best actresses and others to make sure that we can verify and document that they understood. And the [ Indiscernible-distorted audio ] has talked about the teach back methods and I've outlined them for you yet there still considered part of the best actresses. It is very specific to this particular methodology to give back to the client. These are just some examples of what you might do during the process of making sure that person understands their consent.

In the first part you just want to check in. What is this like I want to make sure we have the same understanding about our work together. You want to make sure that you did this and these are examples of things you can say to make sure that the consumer or client understands. And if there is the legally authorized individual present you want to present these questions to both the individual and representative. And in the teach back part two here you are about to -- allow the person to refer back to the document this is to check comprehension not memory. Listen for. He and you want to probe if they use technical terms represented in the form that might not be the type of terminology you believe they would typically use this to make sure that they are fully comprehending what it is.

Here you want to say tell me in your own words or ask what he expect to gain from working with me? Just simple questions. This can happen in a couple different ways. You can talk to the form of individual and ask or you can have them read the form at the very end and pose a couple of questions to make sure they have full copper Hanshin in understanding what they just read and signed. In the last one for teach back number three is to correct any error -- misinformation they may have. Oftentimes where, limited confidentiality minor my say that only other situations where if I tell you something about what I did or a crime I committed you do not have to tell my parents, Lisa go back and clarify that because they are a minor and we do have a responsibility and your parents are able to see and review and understand what is happening in our work

together. You might have to clarify some misinformation that make sure that as we do that clarification we take the onus of it. We are explaining that because it is in any way their fault, we just want to understand our mission & complex process. That helps maintain a mutual spec you need for mutual respect as you are working with them.

Is a similar take away points as last week but the last one talks about mating or ethical obligation and make sure that you verbally cover the consent in addition to the written form. If you remember back to last week we talked about informed consent, this is one of the greatest legal issues that comes when there are violations charges, and that is the failure to provide a corrected in correctly performed informed consent. So it is important to address these beforehand so we can address these of their clients and consumers that are appropriate.

I will go back to the question from earlier on.

This was sent in by Cheryl who is an employment specialist she wants to know how informed consent in decision-making would work with an adult with a disability, and intellectual disability, and coordinating with the informed consent of the legal guardian? The story is Ricky is totally capable and wants to work, that his Guardian only wants them to work a few hours a week, and then go to a day have, because of fear of losing Social Security benefits. The legal guardian does not share all the information with Ricky about work.

That is a challenging question. But I think I have a couple ways to think about that would be helpful. Verse of all interactions that occur between Ricky, his legally authorized representative and himself should happen at the same time as you're talking about information and potential employment options for Ricky that assembly were Ricky should also be present so that whether or not he is able to give consent, he is still present and has the ability to insert his voice into the process. It is really critical for him. Another think to be informed consent also space to talk about benefits specifically and I did not include this in the slide but during the teach back part two component there is a part reason talk specifically about benefits and you can say these are certain financial benefits to the particular process. Social Security is important to a lot of individuals however there are the benefits of making a referral for you to someone who can help you look at what the benefit structure would look like if Ricky was employed 10 hours a week or 20 hours a week or whatever he is able to handle in his own functional capacity. You can make sure that you inform them about a particular service and inquire about whether or not they would be interested in that type of service because it is possible to maintain benefits while gainfully employed and you want to make sure that they are aware of that is a lot of people just are not really aware of all the different processes and programs available to assistant is -- individuals with employment so be sure to provide that information as well.

The last component of that in regards to the caregiver or guardian or authorized representative having a very different view and understanding of and visual capacity -- individual capacity is an important point that is something that should be talked about very clearly with that individual present and with the legally authorized representative, just talk about what your role is rid this harkens back to the very basic of what should be included in the informed consent he wore to the best benefit of the individual which means that you're going to make sure that you are monitoring whether or not they will be negatively impacted.

With a certain level of employment, [ Indiscernible-low volume ] you want to make sure that they know that you're going to work to your best ability to make sure they have opportunity to grow and to develop the highest quality of life [ Indiscernible-low volume ] . These things should be well articulated so that when this situation occurs we can revisit what you talked about earlier and said that it sounds like we are in disagreement about how we should move forward and I really want us to talk more in depth about that so we can make sure that everything is working to the best interest of Ricky.

And if for some reason they feel as though they do not want to move forward because you do have the inclination to push for where you think Ricky's capacity is, you have to present the option for them to withdraw, to withdraw against your suggestion but to withdraw still work with someone else who might be more in line with their overall goals are. Does that protect Ricky in the long run? The ultimate response is if the person does to someone who said okay we will keep it at the very basic level, five hours a week when you know his capacity is more than that, ultimately no. But ethically you have the air obligation by providing all the information and negative and positive consequences of working with you, what your role is and how you will work benefit Ricky and his family. And you have met that bar. You've moved on the most ethical way possible and this does go back to autonomy, and the same with our individual clients have the right to decline medication or to turn down job leads would provide them, their authorized representatives unfortunately have that right as well. And so we have to honor that decision-making process. But we saw that obligation to make sure that we provide as much information as possible so they have something else to think about. So they are informed about the decision they are making now I can impact Ricky in the long run.

That was a lot of information. We did get a couple of other comments. One question was if a person can work full-time do they need a legally authorized representative?

The capacity to have gainful employment typically is not the bar for how a legally authorized representative is designated. That is generally something that is typically developed based on their ability to carry out or manage their financials, their ability to take care of themselves, and those are made outside of their ability to maintain employment. Those are two different things. They can have a legally authorized representative based on challenges have with managing their financial needs and being able to fully maintain their household. That would be completely separate from their ability to maintain employment.

There was another comment that the LIR controls all the money including the representative payee for Social Security.

And those are really difficult situations. I saw that particularly I work with the Social Security administration and the disability determination hearings. There were so many hearings, way more than I was comfortable with, where the legally authorized representative worked diligently to pay a case of the person being far more impaired than they were, then what the medical documentation and testing showed, simply under the guise of maintaining the amount of money or benefit they were getting. Those are really challenging situations. Particularly when a person has a legally authorized representative with no capacity to represent themselves. They are heartbreaking situations actually, but we are limited in our scope and ability to advocate across the board in this particular settings. There are some more you can involve consumer advocates

they have to understand that unless there is a specific challenge or mention of abuse in that particular individual, and we just have very little room to intervene in that particular setting on behalf of the client.

Well, this has been a wonderful discussion. You have taken us all the way to our allotted time. Thank you very much Dr. Donal for joining us today. I like to remind all of our listeners they will be receiving e-mail within a valuation survey link for this session and once you have completed the online survey a certificate of completion will be uploaded to your user portal at the website that will be for two CEU credits. And as always we are offering CRC credits so please contact us via e-mail if you need a CRC form. Thank you everyone for your attendance today and thank you Dr. Donal for a wonderful session and y'all have an excellent day and did excellent week.

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