Introduction
This joint statement was developed cooperatively and approved by the Boards
of Directors of the Canadian Healthcare Association, the Canadian Medical
Association, the Canadian Nurses Association and the Catholic Health Association
of Canada.
Contents
Preamble
The needs, values and preferences of the person receiving care should be the
primary consideration in the provision of quality health care. Ideally, health
care decisions will reflect agreement between the person receiving care and all
others involved in his or her care. However, uncertainty and diverse viewpoints
sometimes can give rise to disagreement about the goals of care or the means of
achieving those goals. Limited health care resources and the constraints of
existing organizational policies may also make it difficult to satisfy the
person's needs, values and preferences.
The issues addressed in this statement are both complex and controversial.
They are ethical issues in that they involve value preferences and arise where
people of good will are uncertain of or disagree about the right thing to do
when someone's life, health or well-being is threatened by disease or illness.
Because everyone's needs, values and preferences are different, and because
disagreements can arise from many sources, policies for preventing and resolving
conflicts should be flexible enough to accommodate a wide range of situations.
Disagreements about health care decisions can arise between or among any of
the following: the person receiving care, proxies,1 family members,
care providers and administrators of health care authorities, facilities or
agencies. This joint statement deals primarily with conflicts between the person
receiving care, or his or her proxy, and care providers. It offers guidance for
the development of policies for preventing and resolving ethical conflicts about
the appropriateness of initiating, continuing, withholding or withdrawing care
or treatment. It outlines the basic principles to be taken into account in the
development of such policies as well as the steps that should be followed in
resolving conflicts. The sponsors of this statement encourage health care
authorities, facilities and agencies to develop policies to deal with these and
other types of conflict, for example, those that sometimes arise among care
providers.
I. Principles of the therapeutic
relationship2
Good therapeutic relationships are centered on the needs and informed choices
of the person receiving care. Such relationships are based on respect and mutual
giving and receiving. Observance of the following principles will promote good
therapeutic relationships and help to prevent conflicts about the goals and
means of care.
- The needs, values and preferences of the person receiving care should be
the primary consideration in the provision of quality health care.
- A good therapeutic relationship is founded on mutual trust and respect
between providers and recipients of care. When care providers lose this sense
of mutuality, they become mere experts and the human quality in the
relationship is lost. When persons receiving care lose this sense of
mutuality, they experience a perceived or real loss of control and increased
vulnerability. Because persons receiving care are often weakened by their
illness and may feel powerless in the health care environment, the primary
responsibility for creating a trusting and respectful relationship rests with
the care providers.
- Sensitivity to and understanding of the personal needs and preferences of
persons receiving care, their family members and significant others is the
cornerstone of a good therapeutic relationship. These needs and preferences
are diverse and can be influenced by a range of factors including cultural,
religious and socioeconomic backgrounds.
- Open communication, within the confines of privacy and confidentiality, is
also required. All those involved in decision-making should be encouraged to
express their points of view, and these views should be respectfully
considered. Care providers should ensure that they understand the needs,
values and preferences of the person receiving care. To avoid misunderstanding
or confusion, they should make their communications direct, clear and
consistent. They should verify that the person receiving care understands the
information being conveyed: silence should not be assumed to indicate
agreement. The person receiving care should be provided with the necessary
support, time and opportunity to participate fully in discussions regarding
care.
- The competent person3 must be involved in decisions regarding
his or her care.
- The primary goal of care is to provide benefit to the person receiving
care. The competent person has the right to determine what constitutes benefit
in the given situation, whether with respect to physical, psychological,
spiritual, social or other considerations.
- Informed decision-making requires that the person receiving care or his or
her proxy be given all information and support necessary for assessing the
available options for care, including the potential benefits and risks of the
proposed course of action and of the alternatives, including palliative care.
- The competent person has the right to refuse, or withdraw consent to, any
care or treatment, including life-saving or life-sustaining treatment.
- Although parents or guardians are normally the primary decision-makers for
their minor children, children should be involved in the decision-making
process to the extent that their capacity allows, in accordance with
provincial or territorial legislation.
- When the person receiving care is incompetent, that is, lacking in
adequate decision-making capacity with respect to care and treatment, every
effort must be made to ensure that health care decisions are consistent with
his or her known preferences. These preferences may be found in an advance
directive or may have been communicated orally. In jurisdictions where the
issue of decision-making concerning care and medical treatment for incompetent
persons is specifically addressed in law, the requirements of that legislation
should be met.
- When an incompetent person's preferences are not known and there is no
family member or proxy to represent the person, decisions must be based on an
attempt to ascertain the person's best interests, taking into account:
- the person's diagnosis, prognosis and treatment options,
- the person's known needs and values,
- information received from those who are significant in the person's life
and who could help in determining his or her best interests, and
- aspects of the person's culture, religion or spirituality that could
influence care and treatment decisions.
- When conflicts arise despite efforts to prevent them, they should be
resolved as informally as possible, moving to more formal procedures only when
informal measures have been unsuccessful.
- In cases of disagreement or conflict, the opinions of all those directly
involved should be given respectful consideration.
- Disagreements among health care providers about the goals of care and
treatment or the means of achieving those goals should be clarified and
resolved by the members of the health care team so as not to compromise their
relationship with the person receiving care. Disagreements between health care
providers and administrators with regard to the allocation of resources should
be resolved within the facility or agency and not be debated in the presence
of the person receiving care. Health care authorities, facilities and agencies
should develop conflict resolution policies for dealing with such issues and
monitor their use.
- When the needs, values and preferences of the person receiving care cannot
be met, he or she should be clearly and frankly informed of the reasons for
this, including any factors related to resource limitations.
- Health care providers should not be expected or required to participate in
procedures that are contrary to their professional judgement4 or
personal moral values or that are contrary to the values or mission of their
facility or agency.5 Health care providers should declare in
advance their inability to participate in procedures that are contrary to
their professional or moral values. Health care providers should not be
subject to discrimination or reprisal for acting on their beliefs. The
exercise of this provision should never put the person receiving care at risk
of harm or abandonment.
- Health care providers have a responsibility to advocate together with
those for whom they are caring in order that these persons will have access to
appropriate treatment.
II. Guidelines for the resolution
of ethical conflicts
Health care organizations should have a conflict resolution process in place
to address problems that arise despite efforts to prevent them. There may be
need for variations in the process to accommodate the needs of different
settings (e.g., emergency departments, intensive care units, palliative care
services, home or community care, etc.).
The conflict resolution policy of a health care authority, facility or agency
should incorporate the following elements, the sequence of which may vary
depending on the situation. The policy should designate the person responsible
for implementing each element. That person should work closely with the person
receiving care or his or her proxy. Anyone involved in the conflict may initiate
the resolution process.
- Clarify the need for an immediate decision versus the consequences of
delaying a decision. If, in an emergency situation, there is insufficient time
to fully implement the process, it should be implemented as soon as possible.
- Gather together those directly involved in the conflict; in addition to
the person receiving care and/or his or her proxy, this might include various
health care providers, family members, administrators, etc.
- If necessary, choose a person not party to the conflict to facilitate
discussions. It is imperative that this person be acceptable to all those
involved and have the skills to facilitate open discussion and
decision-making.
- Identify and agree on the points of agreement and disagreement. While
ensuring confidentiality, share among those involved all relevant medical and
personal information, interpretations of the relevant facts, institutional or
agency policies, professional norms and laws.
- Establish the roles and responsibilities of each participant in the
conflict.
- Offer the person receiving care, or his or her proxy, access to
institutional, agency or community resources for support in the conflict
resolution process, e.g., a patient representative, chaplain or other resource
person.
- Determine if the group needs outside advice or consultation, e.g., a
second opinion, use of an ethics committee or consultant or other resource.
- Identify and explore all options and determine a time line for resolving
the conflict. Ensure that all participants have the opportunity to express
their views; the lack of expressed disagreement does not necessarily mean that
decision-making is proceeding with the support or consent of all involved.
- If, after reasonable effort, agreement or compromise cannot be reached
through dialogue, accept the decision of the person with the right or
responsibility for making the decision. If it is unclear or disputed who has
the right or responsibility to make the decision, seek mediation, arbitration
or adjudication.
- If the person receiving care or his or her proxy is dissatisfied with the
decision, and another care provider, facility or agency is prepared to
accommodate the person's needs and preferences, provide the opportunity for
transfer.
- If a health care provider cannot support the decision that prevails as a
matter of professional judgement or personal morality, allow him or her to
withdraw without reprisal from participation in carrying out the decision,
after ensuring that the person receiving care is not at risk of harm or
abandonment.
- Once the process is completed; review and evaluate: (a) the process,
(b) the decision reached, and (c) implementation of the decision. The
conclusions of the evaluation should be recorded and shared for purposes of
education and policy development.
III. Policy development
Health care authorities, facilities and agencies are encouraged to make use
of an interdisciplinary committee to develop two conflict resolution policies:
one for conflicts among health care providers (including administrators) and the
other for conflicts between care providers and persons receiving care.
Membership on the committee should include care providers, consumers and
administrators, with access to legal and ethics consultation. The committee
should also develop a program for policy implementation.
The successful implementation of the policy will require an organizational
culture that encourages and supports the principles of the therapeutic
relationship as outlined in this joint statement. The implementation program
should include the education of all those who will be affected by the policy
with regard to both the principles of the therapeutic relationship and the
details of the conflict resolution policy. It should also include measures to
ensure that persons receiving care and their families or proxy decision-makers
have access to the policy and its use. The policy should be reviewed regularly
and revised when necessary in light of relevant clinical, ethical and legal
developments.
Because policies and guidelines cannot cover all possible situations,
appropriate consultation mechanisms should be available to address specific
issues promptly as they arise.
Notes
1. The term "proxy" is used broadly in this joint statement to identify those
people who are entitled to make a care and treatment decision for an
incompetent person (in some provinces or territories, the definition of proxy
is provided in legislation). This decision should be based on the decision the
person would have made for himself or herself, to the best of the proxy's
(substitute decision maker's) knowledge; or if this is unknown, the decision
should be made in the person's best interest.
2. The term "therapeutic relationship" is used broadly in this document to
include all professional interactions between care providers, individually or
as a team, and recipients of care.
3. Competence can be difficult to assess because it is not always a constant
state. A person may be competent to make decisions regarding some aspects of
life but not others; as well, competence can be intermittent: a person may be
lucid and oriented at certain times of the day and not at others. The legal
definition and assessment of competence are governed by the provinces or
territories. Health care providers should be aware of existing laws relevant
to the assessment and documentation of incompetence (e.g., capacity to consent
and age-of-consent legislation).
4. Professional judgement will take into account the standard of care that a
facility or agency is committed to provide.
5. On this matter, cf. Guiding Principle 6 of the Joint Statement on
Resuscitative Interventions (Update 1995), developed by the
Canadian Healthcare Association, the Canadian Medical Association, the
Canadian Nurses Association and the Catholic Health Association of Canada,
"There is no obligation to offer a person futile or nonbeneficial treatment.
Futile and nonbeneficial treatments are controversial concepts when applied to
CPR (cardiopulmonary resuscitation). Policymakers should determine how these
concepts should be interpreted in the policy on resuscitation, in light of the
facility's mission, the values of the community it serves, and ethical and
legal developments. For the purposes of this joint document and in the context
of resuscitation, 'futile' and 'nonbeneficial' are understood as follows. In
some situations a physician can determine that a treatment is 'medically'
futile or nonbeneficial because it offers no reasonable hope of recovery or
improvement or because the person is permanently unable to experience any
benefit. In other cases the utility and benefit of a treatment can only be
determined with reference to the person's subjective judgement about his or
her overall well-being. As a general rule a person should be involved in
determining futility in his or her case. In exceptional circumstances such
discussions may not be in the person's best interests. If the person is
incompetent the principles for decision making for incompetent people should
be applied."
Copyright Information
© 1999, Canadian Healthcare Association (CHA), Canadian Medical Association
(CMA), Canadian Nurses Association (CNA) and Catholic Health Association of
Canada (CHAC). Permission is granted for noncommercial reproduction only.
Comments or questions regarding the joint statement or orders for the joint
statement can be sent to: Customer Services, Canadian Healthcare Association, 17
York Street, Ottawa ON K1N 0J6, 613 241-8005, ext. 253, fax 613 241-9481; or
Membership Services, Canadian Medical Association, PO Box 8650, Ottawa ON
K1G 0G8, 800 267-9703, ext. 2307, fax 613 236-8864; or Publication Sales,
Canadian Nurses Association, 50 The Driveway, Ottawa ON K2P 1E2, 613 237-2133,
fax 613 237-3520; or Publications, Catholic Health Association of Canada, 1247 Kilborn Place, Ottawa ON K1H 6K9, 61 373-17148, fax 613 731-7797. Copies of this
joint statement are also available at the following web sites:
www.canadian-healthcare.org (CHA),
www.cna-nurses.ca (CNA) and
www.chac.ca.