Clinical Ethical Decision-Making Framework

Purpose:
The ethical decision making framework is a tool to assist Ontario Shores healthcare providers when dealing with ethical dilemmas involving the care of a patient.


Guiding Principles:
Autonomy
Autonomy refers to a person’s right to make free decisions about his or her healthcare (Singer, 1999) or to take responsibility of one’s self and others as far as one lets them. Consent, capacity, disclosure, voluntariness and confidentiality are all based on this principle. It takes into consideration a patient’s values, experiences, desires and goals.

Beneficence
Beneficence calls for first seeking the good that flows from your role as a healthcare provider. This should consider a patient’s value system.

Non-Maleficence
First, do no harm and do not overstep grounds as a healthcare provider.

Justice
Persons should be treated equal despite age, nationality/ethnic origin, race, sex, sexual orientation, religion, financial and social status and any other medical or moral considerations.

Trust
Trust is central to a therapeutic relationship. It is the provision of information that is accurate and that can be applied. It informs patients about their situation and helps them make choices about their healthcare (Singer, 1999). Other aspects of trust are veracity, privacy, confidentiality and fidelity (faithfulness to a relationship).


Steps for the Ethical Decision-Making Process:
The process for ethical decision-making includes 11 steps:

  1. Identification of the Ethical Dilemma (actual values in conflict need not be identified at this stage)
  2. Acknowledgement of Feelings
  3. Information Gathering
  4. Separation of Legal, Clinical, Ethical and Other Relevant Components
  5. Communication/Consultation
  6. Identification of Ethical Principles Involved and those in Conflict
  7. Analysis
  8. Resolution
  9. Implementation
  10. Evaluation
  11. Prevention
  1. Identification of an Ethical Dilemma
    Central to an ethical dilemma are value choices (i.e. ethical principles and interests), which are presented with much concern, uncertainty, disagreements or ambiguity. (Abdool, 2004)

    An ethical dilemma exists if at least one of the following is presented:

    • An individual/team is not able to articulate the problem that is presented to them but is unsettled by the situation.
    • A decision needs to be made and there are at least two choices, but an individual/team is not sure which choice to make. There may be disagreement among a team as to which choice to make.
    • At least two choices are presented which are all satisfactory and appealing but a decision cannot be made.

    A member of the team identifies an ethical dilemma which they then bring to the attention of the team. If the team confirms the dilemma then the decision-making process may begin.

  2. Acknowledge Feelings
    “Gut” reactions, biases and loyalties (Centre for Clinical Ethics Principle Based Framework)

  3. Information Gathering
    A four-box paradigm for analysis of an ethical case can be used here as part of the process of gathering information. It includes gathering information under each of the following topics: medical indication for intervention, preference of patient, quality of life, and contextual features. The following questions can be asked of each, if applicable (Jonsen, Siegler and Winslade, 1992):
    1. Medical indication
      • What are the patient’s medical conditions (problem, diagnosis and prognosis)?
      • What are the appropriate goals of treatment and possibilities of success?
      • If therapy fails what are the plans?
      • How to provide benefit and avoid harm?
    2. Patient Preference
      • What does the patient prefer?
      • Has the patient (or substitute decision-maker) provided consent? Was the consent process informative, understandable and voluntary?
      • Does the patient (or substitute decision-maker) understand the benefits and risks?
      • Is the patient capable of making decisions (i.e. for treatment, finances or collection, use and disclosure of personal health information)?
      • Who is the decision-maker if the patient is incapable? Are there advance directives or a substitute decision-maker?
      • Who are the stakeholders (patient, family, significant others, substitute decision-makers and healthcare team)?
    3. Quality of Life
      • What are the prospects with or without treatment to return to a normal life?
      • Are there any biases that might prejudice the provider’s evaluation of the patient’s quality of life?
      • If treatment is successful are there any physical, mental or social deficits?
      • Does the patient view their continued life as undesirable to them?
    4. Contextual Features
      • Is this an emergency situation that warrants a decision to be made in a time sensitive manner?
      • Are there any individuals or other factor(s) that are influencing treatment decision?
      • Are there financial issues?
      • Are there any issues or conflicts (religious, cultural, psychosocial, institutional policies/codes or legal)?
      • Any reason to breach confidentiality?
      • Is there a reason to act contrary to patient’s wishes?

  4. Separation Of Legal, Clinical, Ethical and Other Relevant Components
    This separation will help to offer clarity to the ethical dilemma. Each dilemma must be acted upon with team consensus (majority of opinion or general agreement). (Abdool, 2004)

    If the team cannot solve the issues within each component on their own, consultation with appropriate individuals mentioned below should be considered. For further descriptions on the roles of the Director, Risk Management and Patient Safety, Psychiatric Patient Advocate Office (PPAO) and the Ethicist, please refer to the pamphlet called The Relationship between Key Services Provided at Ontario Shores: Ethics, Law, Privacy and Risk Management, Quality and Psychiatric Patient Advocate Office (PPAO).

    1. Risk is the exposure to a hazard which may cause harm to patients, staff, volunteers, visitors or the organization. Risk Management is the process of making and carrying out decisions to prevent adverse consequences and minimize adverse effects of accidental losses. If there is a risk management or legal issue then the Director, Risk Management and Patient Safety may be contacted for resource. Should legal advice be required, the Director, Risk Management may secure consultation with hospital legal counsel.

      Privacy issues pertaining to access, use, disclosure, retention, storage and destruction of personal health information may be referred to the Leader, Privacy, Policy and Procedure.

      Patients, families or staff may obtain advocacy services for patients from the Psychiatric Patient Advocate Office (PPAO). The Patient Advocate may provide services and support which includes resolving issues related to patient’s legal and civil rights. The Rights Advisor may provide the patient or their Substitute Decision Maker with their rights regarding a change in the patient’s legal status.

    2. If there is a clinical component then collaboratively the team, client, and/or substitute decision-maker determine a suitable course of action. Medical and or psychiatric consultation may be considered.
    3. If there is an ethical component and the situation involves values. The Ethicist may be consulted. Please proceed to the next step of this guideline to continue the ethical decision-making process.
    4. If there is a spiritual care component then a Chaplain may be consulted.

  5. Communication/Consultation

    1. A consultation process begins with meetings with the appropriate individuals identified in Step 3.
    2. Relevant Information gathered in Step 2 should be presented.

  6. Identification of Ethical Principles, Duties, Obligations and Conflicts
    1. Identify whether one of the following ethical principles apply to the case:  autonomy, beneficence, non-maleficence, justice and trust. Definitions are described on Page 1 (Guiding Principles section).
    2. Duties and obligations are linked to values to provide meaning to the situation. If justified, certain duties will take precedence over another. Answer the following questions: (Abdool, 2004)
      1. Who are the stakeholders and what are their roles?
      2. What are the healthcare team’s duties and obligations to the patient, families, future patients and community (i.e. identify treatment options and potential outcomes, if applicable)?
      3. What are the duties and obligations of Ontario Shores to the patients, families, future patients and community?
      4. What are the patient’s responsibilities to their own care?
      5. What are the obligations to third party stakeholders (i.e. society and other significant others) as related to this case?
    3. Identify the conflict with the help of the following questions and note that stakeholder value conflicts may influence discussion.
      1. Is the conflict interpersonal (within the interprofessional team), between the patient and/or family and the healthcare team or between the healthcare team and Ontario Shores?
      2. What ethical principles are in conflict in the above situation (i.e. the patient’s autonomy verses beneficence; or patient’s autonomy verses a perceived obligation to society?
      3. Is Ontario Shores or a member of the healthcare team failing to honour an ethical obligation (albeit unwittingly)?
  7. Analysis (Abdool, 2004)
    1. The patient’s wishes or best interest.
    2. Prioritize ethical values that may be in conflict.
    3. Team members share their rationale for the positions they hold.
    4. All alternatives and options should be examined with consideration to foreseeable consequences of each. Exclude unacceptable alternatives. Review, assess and balance the anticipated benefits and the harms and the possibility of them occurring.
      1. Exclude alternatives that are unacceptable.
      2. Make a list of ethically justifiably resolutions starting from the most desirable to the least. At the same time juxtapose selected viable alternatives with pertinent ethical duties and obligations or principles.
  8. Resolution (Abdool, 2004)
    1. List in order the alternatives from the most acceptable and match them with the patient’s values and beliefs while remembering that benefits and harms should be balanced.
    2. At this stage it is important that consensus is reached by the team, and those whose moral positions cannot be reconciled with the alternatives should be invited to not be a part of the team if they chose so. Those who chose not to be a part of the decision must first consider their ethical duties to a patient and consider whether or not harm comes to the patient by their lack of participation. If moral distress exists that goes contrary to one’s conscience and their ethical duties are addressed then this can support choosing to not be a part of the decision.
    3. A course of action should be decided on and it should be morally defended.
    4. If there is still much conflict the Bioethicist can become involved.
    5. Thorough documentation of individuals involved in the decision-making process, meetings and course of actions must take place.
  9. Implementation
    The following should be addressed before implementing the plan for the decision made: (Abdool, 2004)
    • The most appropriate individual should be chosen to implement the decision, and a reason for choosing this person must be provided.
    • Decide on the best time to implement the decision, and explain why.
    • Determine when results are to be expected.
    The decision should be documented in the patient’s health record with a description of the plan for the actions to be taken, its implementation and evaluation.
  10. Evaluation
    • A process should be established to evaluate the effects of the decision and its plan, even on an ongoing basis. Answer the following questions: (Abdool, 2004)
      • Was the dilemma resolved? Were the effects from the decision expected?
      • Was the decision implemented in the time expected?
      • Were there other unforeseen consequences that require further deliberation?
      • Was the decision the most ethically justifiable under the circumstances?
    • The impact of the plan on existing policies for Ontario Shores should be evaluated.
  11. Prevention (Abdool, 2004)
    • What has been learned from the dilemma?
    • What were the factors that contributed to the dilemma?
    • Identify problematic policies? Develop new policies or modify existing policies to prevent the dilemma from reoccurring. Please reference Policy and Procedure, development, Revision and Approval Admin Manual 7.33 for further guidance.

    References


    Abdool, Steve. and Edgardo Perez, and Wilson Lit. Making Ethical Choices:  An Ethical Decision-making Handbook for Health Care Practitioners & Administrators. Second Edition. Guelph, ON. 2004.  (Permission has been granted by Steve Abdool to reference and use the manual for the purposes of Ontario Shores.)

    Jonsen AR, Siegler M, and Winslade WJ. Clinical Ethics. Third Edition. New York, McGraw-Hill. 1992

    Singer, Peter A. Ed. Bioethics at the Bedside:  A Clinician’s Guide. Canadian Medical Association, Ottawa, ON 1999.

    Centre for Clinical Ethics. A Principle Based Framework/Process for Ethical Decision Making. Toronto, ON.