Paula Chidwick1, Robert Sibbald, Laura Hawryluck. 1. William Osler Health System, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, University Health Network, University of Toronto. Paula.chidwick@williamoslerhs.ca
Abstract
PURPOSE: To increase our understanding of the notion of "best interests" in end of life disagreements through an updated review of decisions made by the Consent and Capacity Board of Ontario. There was a significant increase (235%) in decisions from this tribunal between 2009 and 2011. "Best interests" test is used when no prior expressed wishes are known to the surrogate decision-makers. METHODS: Purposively sampled written decisions of the Consent and Capacity Board of Ontario between 2003 and 2011 that focused on the "best interests" of patients at the end of life. Interpretive content analysis was performed independently by 3 reviewers, and themes were identified by consensus. RESULTS: We found substitute decision makers (SDMs) rely on an appeal to their own values or religion in their interpretation of best interests; physicians rely on clinical conditions; board emphasizes alignment with Health Care Consent Act. In the more recent cases, we found that SDMs report that patients value suffering; that SDMs have unrealistic hope for recovery and can communicate and get direction from the incapable patient; that SDMs need education on their role and responsibility as SDM; and that SDMs need time to provide consent, and that most proposed treatment plans that were sources of conflict included "palliative care." INTERPRETATION: Several lessons are drawn for the benefit of health care teams engaged in disagreements at end of life with SDMs over the best interests of patients.
PURPOSE: To increase our understanding of the notion of "best interests" in end of life disagreements through an updated review of decisions made by the Consent and Capacity Board of Ontario. There was a significant increase (235%) in decisions from this tribunal between 2009 and 2011. "Best interests" test is used when no prior expressed wishes are known to the surrogate decision-makers. METHODS: Purposively sampled written decisions of the Consent and Capacity Board of Ontario between 2003 and 2011 that focused on the "best interests" of patients at the end of life. Interpretive content analysis was performed independently by 3 reviewers, and themes were identified by consensus. RESULTS: We found substitute decision makers (SDMs) rely on an appeal to their own values or religion in their interpretation of best interests; physicians rely on clinical conditions; board emphasizes alignment with Health Care Consent Act. In the more recent cases, we found that SDMs report that patients value suffering; that SDMs have unrealistic hope for recovery and can communicate and get direction from the incapable patient; that SDMs need education on their role and responsibility as SDM; and that SDMs need time to provide consent, and that most proposed treatment plans that were sources of conflict included "palliative care." INTERPRETATION: Several lessons are drawn for the benefit of health care teams engaged in disagreements at end of life with SDMs over the best interests of patients.