Consent Service Agreement
Hospice Residence Program

Bethell Hospice strives to provide Hospice Palliative Care in a “home-like” environment according to but not limited to the World Health Organization’s definition of Palliative Care: “prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. A holistic approach is used to provide symptom management and comfort in all the domains of issues: physical, disease management, psychosocial, spiritual, practical, death management, grief, and bereavement. The focus is on the resident’s goals of care and quality of life, not hastening or postponing death. This is provided in collaboration with a multidisciplinary team that includes support 24 hours a day, 7 days a week onsite professional staff including RNs, RPNs, PSWs, social workers and volunteers where family and friends are welcome. Medical Assistance in Dying is not provided on Bethell Hospice premises.

• I, or my Substitute Decision Maker (SDM), consent to receive services from Bethell Hospice. I understand that I may withdraw this consent at any time by verbal notification, which will result in the discontinuation of hospice services.

• I give consent for my personal and medical information to be shared with Bethell Hospice Residence program and with Bethell Hospice Community Services.
• For the purposes of ensuring continuity of care, I authorize Bethell Hospice to receive and to share my personal health information with all healthcare partners within my circle of care.
• I understand that if at any time I no longer wish my personal or medical information to be shared with others, as stated above, then I must notify Bethell Hospice in writing of my request.
• I understand that part of the admission and consent into the Bethell Hospice Residence program requires the completion of the consent process form for Bethell Hospice Foundation. I understand I have the option to consent or decline the sharing of my information with Bethell Hospice Foundation.

• I acknowledge that I have been informed of my rights and responsibilities as a Bethell Hospice client. A copy of the Bethell Hospice Patient Bill of Rights has been given to me.

• I understand that all personal information will be treated as private and confidential as per the Personal Health Information Protection Act, 2004.
• I understand that information sharing between Bethell Hospice personnel shall be for the sole purpose of providing quality service to meet my needs and those of my family. I understand that all personal information will be treated as private and confidential. Safety supersedes confidentiality when persons are at risk.
• I acknowledge that during my stay at Bethell Hospice that I may become aware of some of the private information of other residents.  No one, including other residents or families may share confidential information that they have become aware of. The staff and volunteers sign confidentiality agreements.

• I understand that volunteers are part of the Bethell Hospice team who are trained to work for specific areas with the hospice and contribute to your experience while you are at Bethell Hospice. These include in the areas of residential support, reception, kitchen, facilities, and gardens.

• I understand and accept the conditions noted above. I agree to release and indemnify Bethell Hospice or any directors, officers, volunteers, agents, and employees from all claims and liability for any of the following:
  1. Personal injury, illness, incapacity, or death that occurs, or
  2. The loss of money, valuables, and personal effects unless held in safe keeping by the Hospice.
  3. Loss of property or damage (unless intentionally committed).
  4. Any care provided to me other than by the employees and agents of the Hospice.
• I agree to release Bethell Hospice along with its directors, officers, volunteers, agents, and employees of all actions, claims, or demands of any nature or kind arising out of, or in any way connected with the provision of services by Bethell Hospice except if claims arise from intentional or deliberately harmful or criminal actions.

• Do Not Resuscitate (DNR), Substitute Decision Maker and funeral arrangements have been established prior to admission.

• Curative or invasive medical treatments including but not limited to Intravenous (IV) Therapy, Diagnostic Imaging, blood work, and chemotherapy are not part of the Palliative/End-of-life care provided at Bethell Hospice.
• A physician will be available to support my ongoing care during my admission to and stay at Bethell Hospice.
• Medications will be dispensed by Shoppers Drug Mart (11965 Hurontario St., Brampton) and/or Calea Pharmacy (Mississauga). Ontario Drug Benefit coverage will be provided by the Central West Local Health Integration Network (CW LHIN).
• At times, bed rails may be necessary to ensure resident safety. Bed rails may be used to prevent residents from falling out of bed, repositioning, and increasing a sense of security and comfort. The resident or SDM may or may not consent to the use of bedrails, however, do so at their own risk. Each bed has a bed alarm for further safety.

• Staff and volunteers assist residents with an offering of light food available at any time during their stay. Food specific to resident needs can be brought in by family/friends. Prepared foods can be brought in, stored in the resident’s mini fridge, and can be heated by staff and volunteers. Food intake decreases significantly at the end of life and often switches to food consistency, thickeners and no eating or drinking will occur eventually. Mouth care will continue. Safety is of utmost importance; thus, staff will monitor appetite and safe swallowing throughout the resident’s stay.

• Bethell Hospice endeavors to provide a safe and respectful environment. Deliberate aggressive and/or threatening behavior (physical, emotional, psychological, sexual) is not tolerated towards staff and volunteers of Bethell Hospice, nor other residents, families, and friends. If this occurs, a warning will be issued, police may be called, and/or the individual involved may be banned from Bethell Hospice property.

• Visitors are allowed 24 hours a day 7 days. Visitors are required to sign in on arrival and are encouraged not to visit if they are sick or feeling unwell. Visitors may be limited, required to wear protective equipment (face masks, gloves, and so on), or sign agreements during specific circumstances (outbreak/pandemic, and so on).
• Pets are allowed and must be kept under control in the resident’s room at all times for short visits. It is expected that the visiting animal(s) have up-to-date vaccinations, have had flea/tick treatments and a copy is to be provided for the resident chart. Pet visits may be stopped under certain circumstances (i.e. during an outbreak/pandemic).

• I understand that the services of the hospice residence and community programs are provided at no cost thanks to the generosity of donors, community partners, and government funding. Some medications may incur a cost, and this will be reviewed prior to admission or at the time they are ordered by a doctor. Financial donations, in-memoriam donations, and bequests are gratefully accepted. To discuss donation opportunities. Please contact the Foundation office at foundation@bethellhospice.org.

• Bethell Hospice is committed to providing an accessible experience in which all individuals have equal access to our services and facilities as required by the Accessibility for Ontarians with Disabilities Act, 2005.

I understand that as part of my care at Bethell Hospice, regular assessments will be made. If my condition improves or stabilizes to the point where I no longer require the environment of the residential program at Bethell Hospice, a meeting will be arranged to discuss discharge to an alternate location (for example: home, long-term care) where I can be cared for comfortably. I acknowledge that this agreement does not fall under the Residential Tenancies Act, Ontario 2006, rather than my access is based on my end-of-life needs.

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.