A framework for resolving disagreement during end of life care in the critical care unit.
BACKGROUND
End-of-life decisions regarding the administration, withdrawal or withholding of life-sustaining therapy in the critical care setting can be challenging. Disagreements between health care providers and family members occur, especially when families believe strongly in preserving life, and physicians are resistant to providing medically "futile" care. Such disagreements can cause tension and moral distress among families and clinicians.


OBJECTIVE
To outline the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and to provide a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada.


METHODS
We used a case-based example to illustrate our objectives. We employed a comprehensive approach to understanding end-of-life decision making that included: 1) a search for relevant literature; 2) a review of provincial college policies; 3) a review of provincial legislation on consent; 4) a consultation with two bioethicists and 5) a consultation with two legal experts in health law.


RESULTS
In Canada, laws about substitute decision-making for health care are primarily provincial or territorial. Thus, laws and policies from professional regulatory bodies on end-of-life care vary across the country. We tabulated the provincial college policies on end-of-life care and the provincial legislation on consent and advance directives, and constructed a 10-step approach to conflict resolution.


CONCLUSIONS
Knowledge of underlying ethical principles, understanding of professional duties, and adoption of a process for mediation and conflict resolution are essential to ensuring that physicians and institutions act responsibly in maintaining a patients' best interests in the context of family-centred care.
Choong
Karen
K
Department of Pediatrics and Critical Care, McMaster Children's Hospital, McMaster University, Hamilton, Ontario. choongk@mcmaster.ca
Cupido
Cynthia
C
Nelson
Erin
E
Arnold
Donald M
DM
Burns
Karen
K
Cook
Deborah
D
Meade
Maureen
M
D003422:Critical Care / Q000331:legislation & jurisprudence / Q000379:methods* / Q000592:standards; D003657:Decision Making; D034462:Dissent and Disputes; D019317:Evidence-Based Medicine; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000331:legislation & jurisprudence / Q000379:methods* / Q000592:standards; D009864:Ontario; D010817:Physician-Patient Relations; D011368:Professional-Family Relations