In the current culture of patient safety and best practice, medication or surgical errors are immediately addressed, remedied and reported.  However, when it comes to ethical errors, many treating physicians do not recognize these errors when meeting basic ethical and legal obligations towards incapable patients.

In a review of decisions of the Ontario Consent and Capacity Board, it was clearly shown that there are six common errors in the consent process that have serious ramification on quality of care (Chidwick 2013; Sibbald, R 2010; Hawryluck 2013):
1. Not documenting incapacity for decision making;
2. Not identifying the legally correct decision maker;
3. Not identifying applicable wishes or advance care planning documents that patient’s expressed while capable;
4.  Not acting on applicable wishes patients made while they were capable;
5. Not identifying values and beliefs;
6. Allowing family members or substitute decision makers (SDM) to direct treatment plans, with delivery of treatments that are not medically indicated.

The Checklist to Meet Ethical & Legal Obligations:
1. Reduces ethical and legal errors and improves patient safety;
2. Ensures that teams turn to the capable patient; and if that person is deemed incapable, the team knows to turn to the correct legal substitute decision-maker (SDM);
3. Ensures the SDM understands their role and ensures that the patient’s Advance Care Plans (ACP), wishes, beliefs and values are understood.

The Checklist to Meet Ethical & Legal Obligations was developed and tested in the Osler ICUs through many PDSA cycles in from 2011 – 2014. The Checklist has been directly informed by patient and families throughout its development through quality improvement PDSA cycles and rapid cycle feedback. Learnings from these PDSA cycles have been occurring over the years based on direct input from families, staff and physicians.

The Checklist to Meet Ethical & Legal Obligations is aligned with the wishes, values and beliefs of the patient thereby preventing the occurrence of ethical errors and improving quality of care and patient safety. It ensures that patients receive treatment that they want and can benefit from versus receiving treatments with no known benefits to them that they do not want to receive. When patients receive treatment they do not want, it adversely affects their experience, and it does not align with Osler’s obligations to obtain consent prior to providing treatment. It also places an inappropriate burden to the system because there is no value in providing treatment that is both non beneficial and unwanted.

The Checklist to Meet Ethical & Legal Obligations Checklist minimizes common errors, supports the treatments that the patients want and clarifies what constitutes an end-of-life conversation while respecting professional integrity, and clinical judgment.

Contact Information:

Title: Ethicist and Director Research and Corporate Ethics

Contact email:

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