Clinical Decision-Making Process
This section outlines our Clinical Ethics-Based Decision-Making Workup, a resource to assist with making clinical ethics-based decisions.
This is an elastic process that can be used in various ways, depending on the care the user wishes to take in making a decision and the time available to do so.
All of the steps in the process (except one) are described by the main question the step focuses on:
Tool: Ethics Based Decision Process Workup
To download the Ethics Based Decision Process Workup, please click here.
Step 1 - Identifying the Key Question
- Determine the philosophical problem(s) the group is working to solve
- The question we ask will determine the type and scope of answer we get.
- You want to ensure that the group is working on the same problem and asking the best question to help solve that problem.
- List each as a possible question that the group might tackle.
- For each, ask: if we get an answer to this question, will it provide sufficient direction for us to deal with the issue?
- Select a key question from the list.
- Many questions will present themselves; the challenge is choosing which should be addressed in the time immediately available.
Tips for Success
- Often we want to focus on specific interventions (should we treat the pneumonia, should we attempt resuscitation, etc.), but it’s important to remember that how we answer these will depend entirely upon the goals of care for the patient.
- Focus on a broad question that, if answered well, will likely include more specific ones and will provide meaningful direction for moving forward.
- Some questions are really about missing information. Avoid these, we will get to them in the next section.
- Avoid yes or no questions to allow a broad range of answers.
- Questions that begin with “What should” or “How should” work well.
- Only include descriptors in the question about which there is explicitly shared agreement.
- Try to use honest and accurate, yet morally neutral, language — language that others will be able to hear without feeling threatened or judged.
- While this process looks linear, it does allow movement back and forth between steps. It is just fine to choose a key question, continue with the conversation, then return back to confirm and if need be, alter the question selected.
- Don’t worry if this step seems difficult — it is! Take the time to do this work first.
- It can be helpful for the leader(s) to think about this in advance and come to the meeting with one or two possibilities in mind.
- What should the goals of care be for the patient?
- What should the care plan be for the patient?
- How should we respond to the resident’s request to live at risk?
Step 2 - Summarizing the Facts
- What we know for sure about the context.
- The evidence we have to base this on.
- The information that is missing, but that we can find out (and who will do this research).
- The information that is missing, that we cannot know.
- Develop a shared understanding of the context, including areas
that may be unsettled or controversial.
- Discuss the evidence:
- Is there agreement about the sources of evidence?
- Is there agreement about how this evidence is interpreted?
- Ask specifically if there are any assumptions people believe are
being made that are contentious or unclear and make these explicit.
- Identify the source(s) of the disagreement and if consensus is possible.
Tips for Success
- Ensure that you list beliefs about the world (things that are true or false – often declarative sentences) and not values (what is important to us – often imperatives – “we should”…).
- Remember that reasonable people can understand what reality looks like and how to interpret evidence differently.
- If someone states a belief that is contentious, ask probing questions to understand the source of disagreement.
- Use qualifiers (e.g. sometimes, in most cases) to get to a statement everyone can live with.
- List disagreement about a fact as a fact itself (e.g. there is disagreement amongst the team about the standard of practice.)
- Create subheadings for the facts, if useful.
- Examples include: About the patients and families affected; the system (relevant laws, policies, and processes); the team members involved; the community.
Areas of Information Relevant in the Clinical Setting
Patient clinical history
diagnosis, current treatment, prognosis with various treatment options
patient values and beliefs, understanding of meaning in life, activities and relationships that give their life purpose, the significance of their health condition
Family and loved ones
Who is involved, what their perspectives are.
Care team members
Who is involved, what their clinical opinions are, what their perspectives about what should matter are
Care team dynamics
What institutions and teams are involved in providing care, what their operating cultures are, how these teams get along
relevant laws and policies, broader resource issues
A Fact is a Belief That is True
The more evidence that we have for a belief, the more likely it is a fact.
The quality of a belief will depend on the evidence we have to support it.
“It ain’t what you don’t know that gets you in trouble. It’s what you know for sure that just ain’t so.”
— Mark Twain
Step 3 - Decision Criteria, Important Considerations & Values
- Brainstorm everything that is important that the decision should live up to.
- Ask people to offer full ideas in answering the question “Whatever our answer, it is important that…”
- All considerations should first be named and listed, regardless of degree of importance (so all responses should be accepted).
- Prioritize this list.
- Review the list and confirm the ordering.
- Discuss the justification for the prioritization: why is it reasonable to prioritize and balance in this way?
- Identify values about which there was disagreement and discuss how to address these.
- The resulting list will be the criteria against which the quality of different options will be judged.
Tips for Success
- Make explicit what matters in the situation.
- When a consideration is identified as important, explore whether it is important for its own sake or because it gives us something else of more importance.
- If the latter, be sure to capture both the instrumental and the intrinsic value on the list. For example, if it is important that “all team members clearly chart conversations with a patient about what is important to them while they are in hospital”, is this because it is important, “to minimize exposure to legal liability,” “to ensure consistency of care,” “to best respect the autonomy of the patient,” or “to assist family to understand the perspective of their loved one”? All of these may be important, but some will likely be more important based on the context. So all of the considerations in quotes above should be listed.
- Avoid one word values that are open to interpretation.
Key Values in the Healthcare Encounter
- We make decisions based on the values and beliefs of the patient
- Our decision advances the well-being of the patient, from their perspective
- We do not penalize patients for attributes that are beyond their control
- We do not cause physical harm to our patients
- We do not cause emotional or psychological harm to our patients
- We do not cause harm to others involved in the situation
- The decision reflect the values and beliefs of family members
- We help families to help us understand the perspective of the patient
- We involve members of the family in the manner the patient does or would want
- We honour the integrity of the care team
- We pay particular attention to those who are vulnerable
- We do not abandon the patient
- We support the key relationships in the patient’s life.
How to Prioritize Values
Possible ways to do this exercise include…
- If the group is small enough, collectively give each value statement a score between 1 and 5, where 5 is crucial.
- Write each value statement on a whiteboard or flip chart, and have everyone write their score beside each.
- Give each participant 5 colours of stickers/dots, identify each one with a value between 1 and 5, and ask each participant to place one dot beside a value statement, then tabulate.
Step 4 - Brainstorm Options
This step is aimed at making room for creatively exploring what kinds of solutions, conventional or not, might meet the criteria indicated and answer the key question.
- Have the discussion leader explain the brainstorming exercise.
- Invite members to provide possible ways of answering the question. List these on a flip chart.
Tips for Success
- Do not evaluate options – simply list them. Just because an option is named at this stage does not mean that it will be followed up.
- If anyone challenges an option or offers critical feedback, acknowledge the challenge but don’t engage it; ask that this evaluation be held until the next step.
Step 5 - Consult Others to Confirm and Justify Facts and Values
- Think of whose views need to be understood before an ethically justified response to the situation is possible
- List the individuals, and answer the following questions for each:
- What do we need to understand their perspective about in terms of what reality looks like?
- What do we need to understand about what is important to this person?
- Do we need to understand how this person is feeling about the situation?
- Who will have this/these conversations with this person?
- How/ When will we have this conversation?
- Have these conversations
- Review the previous steps to see what additions and changes need to be made based on this broader view.
There are times when it’s not possible to consult widely.
Inevitably, this will limit the quality of a decision.
So it’s important to do so whenever possible.
Step 6 - Evaluate Options
In this step, we look at the possible solutions to see which ones best live up to the values that are most important:
- List the highest priority values (from Step 4) in the top row.
- Choose some of the options brainstormed (from Step 5) and list them in the first column.
- For each box in the resulting grid, systematically discuss how well the option in question lives up to the value in question. If an option’s consistency with a value depends on some other factor, make these contingencies explicit.
Tips For Success
- Choose options that appeal to the group, but also one or two that at first glance don’t look very good.
- When doing this as a group, put the list of prioritized values next to the list of possible options (flipcharts are helpful for this).
- Then pick an option and go through each of the prioritized values asking, “How well does this option live up to this value?”
Living with integrity involves:
- Identifying what matters the most
- Articulating why this is so
- Carefully choosing a course of action that best allows one to live up to what matters.
Step 7 - Make a Decision and Put it Into Action
- The recommendations are / decision is …
- This recommendation is based on the following values (listed in priority order)…
- Values not supported by this recommendation include…
- We believe this recommendation, and the balancing of values therein, is justified because….
- In this step, we articulate the following: