Decision making

When the answer isn't clear

One of the most difficult decisions that you may face involves a situation where the patient’s wishes aren’t known or documented and your professional assessment of the treatment plan potentially puts you in conflict with a family member or a close friend, or with a provincial law or a service protocol. What is the “right” course of action? Sometimes, the short answer is, “It depends on the situation”.

A proactive strategy is to give thought to these dilemmas before you come face-to-face with them. You may still struggle with finding the answers but you will be better prepared if you’ve taken steps beforehand, such as:

  • Making sure you are well acquainted and current with your local legislation, policies, and procedures by reviewing them periodically.
  • Reflecting on your own beliefs and values, and how these may influence you in these situations.
  • Talking to your colleagues about their thoughts and how they have responded or think they would respond.

Case example:

You are called to homeless shelter for Mrs. Bird, a 55-year-old woman, with a known history of ALS for five years with concurrent bowel CA. When you arrive, you find an emaciated unconscious female with mottled hands and feet, in cardiac arrest with shelter staff providing CPR for approx. 15 mins. Unfortunately, staff does not have Goals of Care/Personal Directive/family members or DNR for this patient. A bystander declares that they were a close friend of the patient and they are adamant that she would NEVER want resuscitation because of how sick she was getting from her cancer and ALS. No other known history is available.

This scenario presents you with a very challenging dilemma. In making a decision as to how to proceed, you’ll need to first answer questions such as these:

  • What are you legally required to do or not do in this situation according to your provincial legislation?
  • What direction do your provincial policies provide regarding goals of care or advance care directives?
  • What are the relevant protocols of your service?
  • What resources does your service direct you to contact for consultation? (e.g., on-call/online services; EMS physician; call group; hospital, etc.)

Sometimes, even with good preparation and after you’ve answered the above questions, you may still not feel you have a clear answer and may need to consult with someone else. Refer to your community guidelines, which will outline policies and procedures for contacting other health care providers. 

Even with clear legal direction, where your decision will have been made for you, this doesn’t necessarily mean it will sit well with you. Remember that these are profound questions about life and death. In the end, you need to make the best decision you can, acknowledging that the circumstances are extremely difficult and that you’ve given the situation the consideration it permits and deserves.