Clinical Ethics for Patients, Families and the Community
The following resources about Clinical Ethics are available for our patients, families and the community
What is Ethics Consultation?
It is often difficult to make health care decisions for one’s self or for another person. For families, it can be especially hard to be the person entrusted with making decisions for another person who is unable to decide for him or herself. For health care professionals, it is not always clear what is in the best interests of a person in their professional care.
There are many different kinds of situations that involve ethical choices. Examples include:
- Deciding when a life-sustaining treatment such as a breathing machine or feeding tube is to be started, continued or stopped
- “We want to do what is best for our father but we don’t know what that is. The medical situation is so complex. How do we decide? Who should decide?”
- “Should we tell our elderly mother that she has cancer and has only a short time to live?”
Patients/residents/clients, families, staff and physicians make ethical decisions every day. Most times we do not need help with these decisions. However, when conflict or difficult questions arise in health care, an Ethics Consultation may help. An Ethics Consultation is a process to work through a difficult ethical decision and get support or assistance from a trained Ethicist.
How can an Ethics Consultation be helpful?
- An Ethics Consultation can assist patients and families, staff and physicians in the identification, analysis, and resolution of moral conflicts that occur in clinical settings.
- An Ethics Consultation provides an opportunity to discuss the tensions that occur in making decisions about health care in a safe, reflective manner.
- People who can offer support with an Ethics Consultation know how upsetting such conflicts may be. They are familiar with the difficult challenges faced in modern healthcare and they provide a supportive, non-judgmental and respectful service.
People who help with Ethics Consultations do not say what to do. They do not make the decision. They are a resource to help clarify one’s own thoughts, feelings and concerns. They can often assist patients, families and health care teams to resolve conflicting values and feelings, and to achieve the best possible outcome for the patient in difficult circumstances. It is important to remember that those who assist with Ethics Consultations do not have the authority to make medical decisions about patient care.
When is an Ethics Consultation helpful?
We all make ethical decisions every day without help. However, we might need to seek assistance if there is:
- Conflict or tension.
- Uncertainty about whether an issue is an ethical one.
- An ethical dilemma, when there appears to be two or more 'right things to do' and it is not clear which is the best way to proceed.
- Moral or ethical distress.
Those facing an ethical issue should consult with the health care team first to problem-solve at that level before requesting a consult.
How can an Ethics Consultation be arranged?
- Talk to members of the health care team about the issue.
- If the problem is not resolved or needs further assistance, any patient, family member, or staff member or physician can request an Ethics Consultation.
- Ethics Consultation is available at each site of St. Joseph's Health Care, London.
To arrange an Ethics Consultation, contact the clinical ethicist at 519 646-6100 ext. 42251
What will happen if an Ethics Consultation is requested?
- The request will be treated with respect and confidentiality.
- A description of the case/issue/situation will be requested to determine if an Ethics Consultation is appropriate.
- If a Consultation is appropriate, a meeting with the relevant people will be arranged. It will be organized as soon as possible, according to the urgency of the situation.
Ethics pocket tool
Questions that Guide the 'Discernment' Process: The Ethics Pocket Tool
Ethical Discernment is the process of focusing on, identifying and addressing ethical issues.
To help with this process, at St. Joseph’s we have developed this summary of the Ethics Pocket Tool:
- Naming the problem: What is the difficulty being faced?
- Who does the problem or situation affect?
- What are the FACTS that relate to the problem?
- What are the principles, values, beliefs & feelings of the parties involved?
- What are the “do-able” options in this situation?
- Which option has the best reasons supporting it?
- Reflect, Critique and Communicate.
Advanced care planning
Advanced Care Planning is a process designed to help people think about and express choices about future personal care. It will ensure that their wishes guide the decisions made for their care and treatment should they become unable to make the decisions. This includes decisions about treatment, admission to long term care and personal assistance services. It can also include the names of the person/people to be appointed to make the decisions for them.
Advanced Care Planning is about:
- making clear how the patient/resident wishes to be cared for, and
- giving someone they trust the authority to act on their behalf.
Let’s talk about it! Advance care planning with your loved ones
For community members and groups, an interactive workshop was developed to help people (families, patients and community members) talk with each other about resuscitation wishes and other End-of-Life wishes. “Let’s Talk About It! Advance Care Planning With Your Loved Ones” is a one-hour interactive workshop that is offered to groups of 10 or more people in the community. Please contact the clinical ethicist to arrange a workshop.
Visit speakupontario.ca for more information.
End of life care
Caring for the body, mind and spirit
St. Joseph’s has a long and strong tradition of providing compassionate care - body, mind and spirit.
Medical advances have brought enormous improvements in the treatment of many conditions and injuries, terminal illnesses, chronic illnesses and the array of complications that come with them. Though advances in care can help people manage illness, death is our common human fate.
How, when, and where we die has changed profoundly in the past 50 years. Because of advanced medical practices individuals can make end-of-life choices regarding life-sustaining care or the decision to end medical strategies.
St. Joseph’s supports individuals making informed decisions about their end-of-life care. This includes talking with family, planning ahead when possible, and deciding when to decline or withdraw treatment (to allow natural death).
St. Joseph’s is a Roman Catholic health care organization, one of 125 across Canada. As such, we respect life from conception to natural death. We consider life a gift and also know that every life comes to an end. We provide end-of-life care and understand some individuals may want to explore medical assistance in dying (assisted suicide and euthanasia) as one of their options.
As a Catholic institution, medical assistance in dying will not occur at any St. Joseph’s location.
Decisions about end-of-life care often require weighing the benefits and burdens of treatment options for the person receiving care. Such decisions take into account the person’s expressed wishes, his or her physical and emotional condition such as excessive pain, suffering, expense or other serious inconvenience, as well as the person’s culture, religion, personal goals, relationships, values and beliefs.
We continue our long tradition of providing excellent care, including palliative care, chronic disease management and mental health care, including suicide prevention, while easing the burden of chronic pain and working with patients and families in their end of life care planning. We have a highly specialized palliative care unit and team at Parkwood Institute. This expert team provides support to many St. Joseph’s programs.
Palliative care, as a philosophy of care, is the combination of active and compassionate therapies intended to comfort individuals and their support communities who are facing the reality of impending death.
Resuscitation is the act of attempting to revive a patient from apparent death. When you are in our care you have options available to you. We have provided some key information below, but as always, it is important to have conversations with your clinical team regarding you wishes.
What is a life-threatening situation?
A life-threatening situation is when a person(s):
- condition deteriorates significantly
- becomes unconscious or a respiratory or cardiac arrest will or has happened
The most serious situation is when breathing stops, or the heart beat becomes irregular or stops, as this leads to death. This is also called ‘vital signs absent’. In hospital, an internal emergency team is called and responds with various methods to try to restore normal breathing and heartbeat. This is known as resuscitation. Patients/residents who require further emergency medical care will be transferred by ambulance to an acute care hospital (e.g. Victoria Hospital at London Health Sciences Centre).
How does this affect me?
Our team will try resuscitation when a patient’s heart or breathing stops. Your physician can tell you more about these procedures for people with your disease/condition. Some patients/residents prefer to allow natural death. Speak with your physician or care team to have your questions answered and discuss your preferences.
What choices do I have?
In discussion, you will be asked: if you are found without vital signs, do you want us to:
- Attempt resuscitation, or
- Do not attempt resuscitation (provide comfort and allow natural death).
Unless you tell us otherwise, we will attempt resuscitation.
We will also ask about your wishes if your condition changes significantly. There are four options ranging from: “Focus on comfort measures” to “Advanced resuscitation level”. Advanced resuscitation level means we will send you in an ambulance to an acute care hospital and they will try relevant procedures available.
Your care provider will explain these choices in more detail.
The physician will:
- explain what is possible for you in a life-threatening situation
- listen to you and be sure you understand the issues and consequences
- answer your questions
- ask what your wishes are regarding resuscitation at the end of your life
- document the decision on a form so all health care providers are aware.
When do I have to decide?
We ask patients/residents when they are admitted to the hospital about their wishes concerning life-threatening situations. There is, of course, always time to ask for more information if you need it.
When you tell us your wishes, those wishes will help guide our care for you if you are unable to speak for yourself.
If an emergency occurs before you have made a decision, the hospital care team will follow its usual practice of attempting full resuscitation efforts.
Can I change my mind?
Absolutely. You can always change your mind. If you do change your mind at any time, please speak with your physician or nurse to discuss your wishes.
Considering your wishes
You may find it helpful to talk to others about your care wishes in a medical emergency. Consider talking to:
- your doctor
- your spouse or partner
- other family members or friends
- someone in your faith group
- your health care team at the hospital.
Sometimes people who are ill become unable to make decisions for themselves. Your Substitute Decision Maker (SDM) will then make decisions about your medical care. It’s important for your SDM to understand your wishes. If you have an advance care directive please bring it with you.
Consent and capacity
People can make their own decisions about health care and treatment when they are capable of doing so. A capable person will understand the information he/she needs to give consent and what might or might not happen as a result of making a decision. This is called informed consent. A person is assumed to be capable unless there is reason to believe otherwise. Consent must be voluntary; the person has a right to make the decision freely, without force, coercion or manipulation.
According to Ontario law, a health practitioner who proposes a treatment for a person shall not give the treatment, and shall take reasonable steps to ensure that it is not given, unless,
(a) he/she is of the opinion that the person is capable with respect to the treatment, and the person has given consent; or
(b) he/she is of the opinion that the person is incapable with respect to the treatment, and the person’s Substitute Decision Maker has given consent on the person’s behalf in accordance with the Health Care Consent Act (1996).
For those patients who are not capable of making their own health care decisions, the legal Substitute Decision Maker will be identified and asked if he/she gives consent for treatment.
The Consent and Capacity Board
The Consent and Capacity Board (CCB) is created to assure the rights of patients. The CCB can hold hearings about diverse matters. It can review the capacity to consent to treatment. It can consider the appointment of a representative to make decisions for an incapable person. It can review the involuntary status of a patient. It can review the decisions of a Substitute Decision Maker; whether the decisions are made in the best interest of the patient.
Hearings can be requested by patients, families and health care professionals.
The CCB conducts hearings under the Mental Health Act, the Health Care Consent Act, the Personal Health Information Protection Act, the Substitute Decisions Act and the Mandatory Blood Testing Act. CCB members are psychiatrists, lawyers and members of the general public.
For more information about when, why and how to consult the Consent and Capacity Board:
Medical Assistance in Dying (MAID)
St. Joseph’s has a long and strong tradition of providing compassionate care - body, mind and spirit.
As a Catholic institution, medical assistance in dying (assisted suicide/voluntary euthanasia) will not occur at any St. Joseph’s location. While Catholic health care does not include hastening death or intentionally ending life, St. Joseph’s excels in end-of-life care. We also work closely with our patients on advanced care planning.
At St. Joseph's we respond to patients and families with compassion and understanding without discrimination. We will listen intently as you discuss your circumstances and your quality of life. We will work with you to ensure you are aware of all resources available to address your physical, emotional and spiritual needs.
We support patient choice and will respect the person who is making that choice. This includes informing the person of options for care and at the request of the patient transferring care to another facility. If a person wishes to discuss medical assistance in dying, St. Joseph's physicians and staff will support a respectful discussion, providing information to you about medical assistance in dying.
For information on eligibility criteria go to the Ministry of Health’s website.
As a patient, if you have any questions regarding MAID please contact Marleen Van Laethem, our clinical ethicist or a member or your care team who can help to answer your questions.
- Catholic Health Alliance of Canada physician hastened death resources
- Medical Assistance in Dying policy and additional resources from the College of Physicians and Surgeons of Ontario (CPSO)
- Medical assistance in dying and end-of-life care preliminary guidance to patients and health care providers from the Ministry of Health and Long-Term Care.