title: The standard of care and conflicts at the end of life in critical care: lessons from medical-legal crossroads and the role of a quasi-judicial tribunal in decision-making.
abstract: OBJECTIVE
  The goals of this qualitative study were to review the last 7 years of end of life legal decisions within the critical care field to explore how medical benefit is defined and by whom and the role of the standard of care (SoC) in conflict resolution.
  
  
  METHODS
  A public online, non-profit database of the Federation of Law Societies of Canada was searched for relevant Consent and Capacity Board decisions from 2003 to 2012. In total, 1486 cases were collected, and purposive sampling identified a total of 29 decisions regarding use of life-sustaining treatments at end of life. Using modified grounded theory, decisions were read and analyzed from a central SoC concept to understand definitions of benefit, rationales for case adjudication, and repercussions of legal recourse in conflict resolution.
  
  
  RESULTS
  Medical benefit was clearly defined, and its role in determining SoC, transparent. Perceptions of variability in SoC were enhanced by physicians in intractable conflicts seeking legal validation by framing SoC issues as "best interest" determinations. The results reveal some key problems in recourse to the Consent and Capacity Board for clinicians, patients and substitute decision makers in such conflict situations.
  
  
  CONCLUSIONS
  This study can help improve decision-making by debunking myth of variability in determinations of medical benefit and the standards of care at end of life and reveal the pitfalls of legal recourse in resolving intractable conflicts.
authors.affiliation: University Health Network, University of Toronto, Toronto, ON, Canada M5G 2C4.
authors.forename: Laura
authors.initials: L
authors.lastname: Hawryluck
authors.forename: Robert
authors.initials: R
authors.lastname: Sibbald
authors.forename: Paula
authors.initials: P
authors.lastname: Chidwick
mesh_terms: D002170:Canada; D003657:Decision Making; D004992:Ethics, Medical; D006801:Humans; D017008:Negotiating; D010166:Palliative Care / Q000941:ethics / Q000331:legislation & jurisprudence; D036301:Qualitative Research; D059039:Standard of Care; D013727:Terminal Care / Q000941:ethics / Q000331:legislation & jurisprudence*; D020458:Third-Party Consent / Q000941:ethics / Q000331:legislation & jurisprudence; D028761:Withholding Treatment / Q000941:ethics / Q000331:legislation & jurisprudence
keywords: Critical care; End of life; Ethics; Law; Standard of care