Case scenario: Order for Botox administration
Daniel, a nurse, wants to begin administering Botox to patients for cosmetic purposes, but does not have the authority to perform this activity. He knows Kate, a family physician, from their children’s school. When he sees Kate at a school function, he asks if she can write the order for Botox, and offers her 10% of the proceeds. Kate declines, saying that she is unable to safely delegate because she has never administered Botox or any other dermal filler, and because no doctor-patient relationship exists.
What is delegation?
Delegation occurs when a physician authorized to perform a controlled act1 confers that authority to someone else. Delegation can be a challenging area for physicians, since the level of direct guidance varies widely across the country. In Ontario, for instance, the Regulated Health Professions Act and the CPSO’s Delegation of Controlled Acts policy both address delegation. However, in many jurisdictions, there are no specific laws or College policies that guide delegation.
When is delegation appropriate?
Regardless of whether your jurisdiction has a specific law or policy on delegation, the same general principles apply. In order to delegate safely, you should ask the following questions:
- Can you competently perform the activity in question? Any activity you plan to delegate must be within your scope of practice, and you must have the knowledge and experience necessary to perform the activity yourself. In the case scenario, although administering an injection is clearly within a family physician’s scope of practice, the physician had no experience injecting Botox or dermal fillers, so delegation was not appropriate.
- Can you provide appropriate supervision and monitoring? While direct supervision may not be required in every case, the level of supervision necessary for safe delegation will generally depend on: the act being delegated and the risk it entails; the patient’s specific circumstances; the setting where the act will be performed; and the skill of the delegate.
- Does the person you’re delegating to have the required knowledge, skill, and judgment? To ensure safe care, a physician should have previously observed the individual perform the activity, or had a discussion with the individual to ensure they have the knowledge, skill, and judgment necessary to perform the activity and obtain informed consent from the patient.
- Does a doctor-patient relationship exist? In the absence of broad standing orders for delegation (such as those used in hospital settings), a physician is expected to have assessed the patient before delegation can occur. The physician should also re-assess the patient whenever a change in treatment is contemplated.
In Québec, healthcare professionals are only permitted to perform acts authorized by their relevant governing legislation and in accordance with any specified requirements. Accordingly, physicians can only request that another healthcare professional perform a reserved act if the legislation governing the other healthcare professional authorizes them to perform that act.
Delegation in specific situations
Delegating to other healthcare providers
When a healthcare provider performs an authorized act within their scope of practice, physician delegation or supervision is not required. A physician who is asked to delegate or adopt a supervisory role in these circumstances may unnecessarily assume responsibility, and expose themselves to liability for acts the other provider was already authorized to perform independently. If you are considering delegating to another healthcare provider, and have questions about their scope of practice, contact the provider’s regulatory authority.
Some jurisdictions have specific policies around delegating cosmetic procedures (such as Botox and dermal fillers) outside of an existing doctor-patient relationship. For example, see the CPSO’s Advice to the Profession: Delegation of Controlled Acts, and the CPSBC’s practice standard on Injection of Botulinum Toxin, Dermal Fillers and Venous Sclerotherapy. As with any other delegated act, the delegation of cosmetic procedures requires: competence on the part of the delegating physician; supervision and monitoring of the delegate; an assessment of the delegate’s skill, knowledge, and judgment; and assessment of the patient by the physician.
The bottom line
Delegation works well in many situations, and a physician can appropriately delegate many acts to other healthcare providers. However, a physician could be subject to a lawsuit or College complaint if the delegated act leads to patient harm, and the physician was aware that:
- the delegate was not capable of performing the act safely
- delegation was not appropriate in the case of that particular patient
- the delegation was not sufficiently precise, or
- there was insufficient supervision.
Carefully assessing whether delegation is appropriate in each situation can help reduce medico-legal risk. Physicians are encouraged to review College policies or standards, and any applicable legislation related to delegation in their jurisdiction.
Delegation and CMPA’s Extent of Assistance
Physicians and their employees may be named in legal actions arising from delegated tasks. CMPA members are generally eligible for assistance for medico-legal matters arising from clinical care in which they are named even if actions or omissions of their employees are at issue. However, CMPA assistance will only be available to employees of physician members if they meet the CMPA’s Principles of Assistance to Clinics and Facilities.
Different jurisdictions use different terms to refer activities that can be performed only by certain healthcare professionals. For example, the term “controlled act” is used in Ontario, while the term “restricted activity” is used in Alberta. The same principles apply regardless of the term used.