On occasion, it is possible that a patient or client may ask you to provide care or to make recommendations that are not clearly part of dietetic scope. This may come about when your dietetic scope (and individual scope), the CDBC Code of Ethics, and the best interest of the client do not align with what your client is requesting of you.
An important part of being a regulated health professional is knowing your limits and staying within your legal scope, as well as your personal scope, while also providing patient-centred care. These considerations can help you avoid situations that are beyond your skill set. If you are asked to perform a risky task that is not within your scope or beyond your competence, you should know and understand which health professional to refer to/consult with. You can also refer to the Decision Tool for New Aspects of Dietetic Practice to help you make decisions.
Some examples could include:
Q: My client would like me to counsel him on a ketogenic diet, for which there may be limited support in research.
A: It is unethical for a dietitian to recommend any nutrition care plan for which there is a lack of evidence. It is important to distinguish what are your recommendations versus the client’s wishes. In the situation described above, it is expected that after conducting your assessment, you would advise the client on your own recommendations and the potential risks and benefits of the ketogenic diet, describing the state of the evidence to support the diet (e.g., for long-term weight loss, to aid in specific medical conditions, etc.) The client may choose to pursue the diet despite the lack of evidence that it works or other risks. In this case, it is important to observe Standard of Practice #12: “A Dietitian provides quality professional services that reflect the unique needs, goals, values and circumstances of the client.”
If you are unable to counsel the client in his/her desire for a ketogenic diet due to ethical concerns, or if teaching the ketogenic diet is outside of your personal scope, you may refer to policy QAC-06 Right to Refuse Treatment. This policy mandates that you “(1) inform the client of your concerns, (2) give reasonable notice of termination of treatment and, (3) offer alternative options to ensure that the client’s nutritional care needs are being met.” Regardless of whether you counsel the client or refer the client to another dietitian for ketogenic diet counseling, it is important to document the encounter thoroughly, based on the CDBC Standards for Record Keeping.
Q: My patient’s family member is asking about using a blenderized enteral formula or an unapproved commercial enteral formula for their loved one. What should I tell them?
A: Commercially prepared enteral nutrition (EN) formulations that do not meet the regulatory requirements for federal food regulation are not appropriate for use and should not be recommended in Canada. To do so would be considered unsafe dietetic practice. If a client chooses to use an EN formulation that has not been approved by Health Canada, which includes the Canada Food Inspection Agency (CFIA) and the Health Products and Food Branch (HPFB), you should advise the client that the product is inappropriate and recommend a suitable EN formulation. If you have questions about a food or natural health product, you can contact Health Canada.
An exception exists when you have recommended a formula that meets the required regulations, but the client has chosen to use an unregulated product. If it is within your individual scope of practice, you may work with the client to determine the amount and rate of feed of the unregulated EN product. This complies with Principle 5 of the CDBC Code of Ethics where “A Registered Dietitian demonstrates respect, dignity and privacy at all times when interacting with clients at by… including the client or substitute decision maker in discussions of service provision and by… inviting the client to make choices .”
You must be aware of the legal implications in the event of an adverse event occurring related to the use of an unregulated commercial product while under your care. You must document all encounters thoroughly and continue to recommend appropriate EN formulations. Additionally, you should consult with your employer and your insurance provider for liability coverage to make sure these interventions are supported.
It is within dietetic scope to counsel clients on the preparation and use of blenderized EN as an alternative to commercially prepared formulas. However, you must assess if this task is within your personal scope.
If your client is requesting to use unregulated commercially prepared EN formulas or the use of homemade blenderized EN and you are not comfortable supporting the client, you have a right to refuse to provide treatment as per policy Qac-06: Right to Refuse Treatment. However, in doing so, you also have a duty to refer the client to another RD who is comfortable in taking over the client’s care.
Q: My client is a minor and her parents are insisting for me to report back to them after a one-on-one session with her. Should I disclose this information? Does she require parental consent to be seen?
A: Refer to “Where’s the Line?” Professional Boundaries in a Therapeutic Relationship, the College’s Patient Relations Program. Page 6 reviews important steps to setting the stage for a therapeutic relationship, including consent to care guidelines.
Consent should be obtained from the minor, given that you are providing a service to her, regardless of whether her parents are present or not. Consent should be obtained in accordance with CDBC Standards for Record Keeping, which includes the requirement to comply with part 2 of the Infants’ Act.
The BC Branch of the Canadian Bar Association has published The CBA Child Rights Toolkit regarding competency, capacity, and consent, which is relevant to physicians and other health care providers. Within this document, children (anyone under 19) can consent to their own medical care if they are “capable” (i.e. if he/she understands the medical care requested, the treatment process, and the risks and benefits of care). Children who are capable can normally obtain medical treatment without their parents’ or guardian’s knowledge or consent. You are unable to discuss a capable minor’s medical care with her parents or guardian unless your client agrees.
It is recommended that you review the Interpretive Guidelines—Privacy Legislation for Private Practitioners along with the Standards for Record Keeping, particularly with respect to Standard 3: “Dietitians ensure a comprehensive client health record is maintained when individual nutrition assessments and interventions are provided.” There is no requirement to have a separate chart for the client’s care and one for the client’s mother. The child (and not the child’s parent) is your client; all documentation related to the care of your client, should be included within one chart.
Q: My client reports poor pain control and would like me to recommend a cannabis product as well as how to use it appropriately for pain control. Can I do this?
Although cannabis is legal in Canada, it is a scheduled drug and recommending or prescribing drugs in the context of managing a disease or medical symptom is a restricted activity that dietitians are not authorized to perform. If you receive requests from a client for medical/therapeutic cannabis, whether related to dietetics (such as appetite stimulation) or not (such as headache), you must refer your client to their physician and collaborate with them.
Q: My family member is requesting counselling from me. Can I provide nutrition services to a family member?
This situation could be perceived as a breach of professional boundaries and a conflict of interest, in that you already have a personal relationship with a family member and this may prevent you from providing objective, ethical and competent care. Entering in a therapeutic relationship under these circumstances is strongly discouraged. While it is discouraged, it is not formally banned by the CDBC. There are a few considerations to help you make an informed decision.
1-You are encouraged to review CDBC’s resource: Where’s the Line? Professional Boundaries in a Therapeutic Relationship. It may be helpful in understanding why it is important to separate personal and therapeutic client relationships as much as possible.
3-If your family member does not wish to seek out or consent to dietetic care from another dietitian (or another dietitian is not available in your community), it is important to determine if withholding dietetic care from a consenting client will cause your family member harm. The function of the CDBC is to protect the public and while doing so, it is not the intent to withhold dietetic care.
4-The point above must be weighed against your personal comfort in providing care to your family member. You should consider situations such as:
- Your ability to maintain confidentiality and privacy among other family members and acquaintances
- Your ability to maintain objectivity in your counselling sessions
- Your ability to interact directly with your client without avoiding difficult conversations regarding the severity of medical conditions.
- The effect of your professional interactions on your long-term personal relationship with your family member.
- Your ability to handle disagreements and accept choices made by your family member even if you disagree with them
- Your ability to handle billing and potential pressure to provide services for free or at a reduced rate? If your family member says they will pay and fail to do so, how will you deal with the situation?
- Your readiness to discontinue services if necessary and/or refer to someone else
- Your ability to maintain your professional obligations, regardless of the nature of the relationship, such as complying with all record keeping requirements
Q: If a patient discloses confidential information to me after being referred by a doctor and requests the information remain confidential between myself and the patient, can it legally remain confidential? Am I obligated to tell the doctor about anything related to nutrition that might affect the patient’s condition?
A: If it has not been consented to, or if it has been expressly denied, you may not disclose personal dietetic-related information about a patient to their physician, unless the failure to disclose could cause significant harm to your client or others. You should continue to work with the patient to encourage consent so as to provide full disclosure of the patient’s status and care to the admitting or most responsible physician, such that optimal care can be provided. In the absence of consent, you should advise the physician that they do not have full information about the patient, but that due to confidentiality, you are not permitted to disclose more. It is important for you to understand the privacy legislation (for private practitioners: Personal Information Protection Act – PIPA; for public healthcare practitioners: Freedom of Information and Privacy Protection Act – FIPPA) as it pertains to your situation and in some circumstances such as this one, you are encouraged to seek legal counsel. If you work for a Health Authority, it is also important that you understand your workplace policies on these situations. You should speak with a manager or supervisor to determine the limitations/expectations on your involvement with your patient.
While these examples are not meant to be exhaustive, if you have a specific situation that you have encountered in your practice that leaves you wondering how to proceed, or if you can proceed with dietetic care, please reach out to the CDBC for help.