Notes
APPENDIX 1-3
An Ethical Decision-Making Framework for Individuals
Michael McDonald (adapted by Rosalie Starzomski and Patricia Rodney)
1. COLLECT INFORMATION AND IDENTIFY THE PROBLEM(S)
a. Identify what you know and what you do not know, but need to know. Be prepared to add/update your information throughout the decision-making process.
b. Gather as much information as possible on the patient’s physical, psychological, social, cultural, and spiritual status, including changes over time. Seek input from the patient, as well as the patient’s family, friends, and other health care team members.
c. Investigate the patient’s assessment of their own quality of life and their wishes about the treatment/care decision(s) at hand. This includes determining the patient’s decision-making capacity, as well as determining which family member(s) the patient wants involved in discussions and decision making about their treatment/care. If the patient does not have decision-making capacity, look for an advance directive. Identify a substitute decision maker for a patient who does not have decision-making capacity and seek evidence of the patient’s prior expressed wishes. Regardless of the patient’s decision-making capacity, involve the patient as much as possible in all decisions affecting them.
d. Include a family assessment: What are the various roles, relationships, and relevant “stories”?
e. Consider implications for social justice. Identify areas where patient and family resources for health and health care may be compromised.
f. Identify the health care team members involved, and circumstances affecting them.
g. Summarize the situation briefly, but with all the relevant facts and circumstances. Try to get a sense of the patient’s overall health and illness trajectory. Determine what is most important to the patient at this stage of their illness and what their wishes are for the future.
h. What decisions have to be made? By whom?
2. SPECIFY FEASIBLE ALTERNATIVES FOR TREATMENT AND CARE
a. Use your clinical expertise to identify a wide range and scope of alternatives. Avoid binary thinking (such as treat/do not treat) and lay out carefully tailored alternatives for the problems you have identified.
b. Identify how various alternatives might be implemented (for example, limited time trials of treatments).
3. USE YOUR ETHICS RESOURCES TO EVALUATE ALTERNATIVES
Principles/Concepts
Autonomy: What does the patient want? How well has the patient been informed and/or supported? What explicit or implicit promises have been made to the patient?
Nonmaleficence: Will this harm the patient? Others?
Beneficence: Will this benefit the patient? Others?
Justice: Consider the interests of all those (including the patient) who have to be taken into account. Are biases about the patient or family affecting your decision making? Treat like situations alike.
Fidelity: Are you fostering trust in patient/family/team relationships?
Care: Will the patient and family be supported as they deal with loss, grief, and/or uncertainty? What about any moral distress of team members? What principles of palliative care can be incorporated into the alternatives?
Relational Autonomy: What relationships and social structures are affecting the various individuals involved in the situation? How can these relationships and social structures be used?
Standards
Examine professional norms, standards and codes, legal precedents, health care agency policy.
Personal judgments and experiences
Consider your personal judgments and experiences, and those of your colleagues, as well as other members of the health care team.
Organized procedures for ethical consultation
Draw on the expertise of other health care providers as needed, and use the ethics resources available in the health care agency. Consider formal case conferences, an ethics committee meeting, and/or inviting an ethics consultant to provide assistance, especially if the situation is complex and/or conflicted.
4. PROPOSE AND TEST POSSIBLE RESOLUTIONS
a. Select the best alternative(s), all things considered.
b. Perform a sensitivity analysis. Consider your choice(s) critically: Which factors would have to change to get you to alter your decision(s)? Further, carefully consider whether you want to maintain or change your previous choice(s).
c. Think about the effects of your choice(s) upon the choices of others. Are you making it easier for others (health care providers, patients and their families, etc.) to act ethically?
d. Is this what a compassionate health care provider would do in a caring environment?
e. Formulate your choice(s) as a general maxim for all similar situations. Think of situations where it does not apply. Consider situations where it does apply.
f. Are you and the other decision makers still comfortable with your choice(s)? If you do not have consensus, revisit the process. Remember that you are not aiming at the perfect choice, but the best possible choice. If no consensus is forthcoming, is it possible to reach a compromise?
g. Ensure that there is a clear implementation plan. Ensure that the rationale and details of the plan are clearly communicated to all those who will be affected (patient, family, and health care providers). Be sure that the implementation plan includes feedback from relevant individuals (the patient, family and friends, health care providers).
5. MAKE YOUR CHOICE
Live with your choice and learn from it! Seek feedback on the process from all those involved. Take the opportunity to reflect on how you will deal with other challenging situations in the future. Consider organizing follow-up debriefings, continuing education sessions, and, if needed, make changes to related policies and procedures.