Appendix A: Key communication principles and schemata from literature
Communication and Ethics Workshop for Critical Care Trainees
Background
Communication skills are critically important when caring for patients at the end of life. In a
recent Canadian survey, seriously ill patients and their family members identified
communication and trust as two of the three most important elements in their care (Heyland
2006). Nevertheless, studies routinely show that seriously ill patients and their families are
unhappy with the frequency of communication with physicians (Teno 2000, Heyland 2003).
The quality of communication is similarly disappointing. Most end-of-life conversations
are short (~5 minutes), with the physician speaking the majority of time (Tulsky 1998). The
SUPPORT trial, which studied communication with 9105 seriously ill hospitalized patients in the
US, found that only one-third had a documented discussion about resuscitation, and only onehalf of patients who didn’t want CPR had a DNR ordered in their chart. Even when US law
mandated such discussions with all patients, neither of these numbers improved (Teno 1997).
In Canada, the CARENET group recently surveyed 600 seriously ill hospitalized patients and their
family members, and found that only one-third had discussed CPR with their physician, only
11% could describe more than 2 components of CPR, and only 2% knew that their chance of
survival following CPR was less than 10% (Heyland 2006). In the ICU itself, communication is
little better- one French survey found that more than half of the relatives of patients in the
Intensive Care Unit (ICU) didn’t understand the diagnosis, prognosis or proposed treatment for
their loved ones following a meeting with a physician (Azoulay 2000).
These well-documented shortcomings have focused attention on the need for an
improvement in communication skills among physicians, and led to initiatives such as EFFPEC1
and the Ian Anderson Continuing Education Program in End-of-Life Care, which include an
emphasis on communication. Academic medicine, on the other hand, has been slow to
respond. Communication skills are not formally taught in most residency programs, and very
few studies have evaluated the utility of teaching communication skills to medical trainees. In
2000, the Canadian Senate lamented the low priority of “compassionate and comprehensive”
end-of-life care in educational programs (Carstairs 2000).
Critical Care Physicians are regularly required to communicate bad news or complicated
medical information to families with little medical experience, often in a very emotionallycharged atmosphere. Conflicts and disagreements arise, and they must be resolved in
accordance with legal and ethical principles. This is a difficult process, and very few critical care
training programs teach their trainees how to manage it. As a result, trainees are left to learn
by experience, which is unfair to families. One recent French study found that families were
significantly less satisfied following communication with junior physicians than senior
physicians (Moreau 2004).
1
Educating Future Physicians in Palliative and End-of-Life Care
The SUPPORT trial demonstrated the difficulty of designing interventions to improve
communication. In the initial phase of this trial, observers followed seriously ill patients who
were admitted to hospital in order to determine whether their physicians knew their wishes
regarding resuscitation and life support, and whether they were experiencing significant pain.
They found that only 47% of physicians knew when their patients wished to avoid
cardiopulmonary resuscitation. In the second phase of this trial, physicians were given
prognostic information about their patients, and specially-trained nurses were hired to speak
with patients, families and physicians in order to ensure proper communication about
resuscitation and life support. Despite these additional resources, communication did not
improve (SUPPORT).
Unlike many aspects of medicine, communication is poorly studied and poorly
understood. However, a few investigators have identified key elements of communication that
help improve understanding, increase patient and family satisfaction, and reduce emotional
trauma. There are also simple communications schemata that have been developed by senior
physicians based on their experience over years of communicating with patients and families.
Finally, we have provided some useful phrases to use in end-of-life or resuscitation
conversations. The use of professionals to portray patients and family members is validated
(Becker, De Champlain), and has been used in the past to improve communication skills among
physicians (Fallowfield).
There is no right way to communicate. Everyone will develop their own technique. The
purpose of this workshop is to help gain experience in a realistic environment, allowing
reflection and immediate feedback that could not take place in the real world.
Evidence-Based Elements from Literature:
Setting
 Find a nice, private, quiet place with seating (Abbott 2001).
 Make sure you have adequate time (Back).
Style
 Let the patient/family talk (Lautrette 2007)
 Always acknowledge the primary caregiver, and ask if the patient had previously spoken
about their end-of-life preferences- this can lessen the emotion burden of decisionmaking (Abbott 2001).
 Acknowledge patients’ emotions, and allow silence (Back, Alexander)
 Use simple and honest terms, tailored to the audience (Back).
Information
 Give prognostic information as early as possible, along with the appropriate degree of
uncertainty (Back, LeClaire 2005).
 Discuss treatment options (Back), but give advice: 85% of patients and 90% of family
members either want advice or want MD to decide (Heyland 2006).
Role-Modelling
 Observe more senior physicians. Families report higher satisfaction following
communication with more senior ICU physicians (Moreau).
Communications Schemata:
CLASS (Baile and Buckman)– For all patient encounters.
Context: Sit together in quiet place, with family present.
Listening Skills: Open-ended questions with active listening, pauses.
Acknowledge: Acknowledge emotions and respond.
Strategy: Propose a strategy (think about this beforehand) and aim for consensus.
Summary: Precis of the conversation, elicit questions, and plan for next meeting.
VALUE (Lautrette et al.)- From conversations about withdrawal of life in ICU.
Value and appreciate what they say
Acknowledge emotions
Listen
Understand who the patient was as a person,
Elicit questions from family.
Overview of an ICU Conference (Adapted from Curtis 2001)
Making preparations before an ICU family conference about end-of-life care
Review previous knowledge of the patient and/or family.
Identify the substitute decision-maker
Review previous knowledge of the family’s attitudes and reactions.
-beliefs, worries fears, coping abilities and style
-preferred communication style, support mechanism and intra-family dynamics
Review content of previous discussions with family
-will your discussion reflect a marked change in Rx course?
Review your knowledge of the disease—prognosis, treatment options.
Discuss Rx options with any involved consulting/surgical teams and develop a consensus
recommendation re future Rx plans.
Decide what decisions if any need to be made and the timing required ( ie do these need
to be made now, is there time for the family to reflect?)
Ensure multiprofessional involvement in development of Rx plans and presence at
meeting
Examine your own personal feelings, attitudes, biases, and grieving (particularly in relation
to the patient and family you are going to speak with).
Plan the specifics of time, location and setting: a quiet, private place.
Discuss with the family in advance about who will be present.
Holding an ICU family conference about end-of-life care
Introduce everyone present.
If appropriate, normalize the conversation: “This is a conversation we have with all
families . . .”
Discuss the goals of the specific conference.
May be vague initially: “We are coming to a point at which decisions need to be
made. We need to talk about these in view of what your father would have
wanted.”
Find out what the family understands and what questions they have—clarify
misconceptions.
Review what has happened and what is happening to the patient.
Discuss prognosis frankly in a way that is meaningful to the family.
Acknowledge uncertainty in the prognosis and treatment.
Review the principle of substituted judgment
“What would the patient want?” - in context of their values and beliefs
“What would be a reasonable goal of care?”
Support the family’s decision and provide emotional spiritual and psychological support as
needed.
Do not provide false hope, but don’t extinguish all hope; consider redirecting hope toward
a comfortable death with dignity if appropriate.
Avoid temptation to give too much medical detail and to use jargon when uncomfortable.
IF WITHHOLDING OR WITHDRAWING LIFE-SUSTAINING TREATMENTS
Make it clear that withholding life-sustaining treatment is not withholding caring.
Make explicit what care will be provided including symptom management, where the care
will be delivered, and the family’s access to the patient.
If life-sustaining treatments will be withheld or withdrawn, discuss issues of time and
timing
Explain what the family is likely to see and experience, whether they can/have to be
present and how comfort will be assured. Respond to fears of family even if they
hesitate to raise them
“You will notice that your father’s breathing will look different as the ventilator is
removed, however he will not feel like he is short of breath….”
“When we remove our machines we are not sure how long your father will be with us.
We will however make sure that he is kept comfortable for as long as he is with
us”
If you plan to extubate, explain what is involved and how comfort will be ensured
Offer to help call family and friends who may not be present. Offer to help break the news
to children and/or to help support children through the grieving process.
Offer support of Chaplaincy services
Use repetition as appropriate to show that you understand what the patient or family is
saying.
Acknowledge strong emotions and use reflection to encourage patients or families to talk
about these emotions.
Understand and accept silences.
Express empathy and support throughout the conversation and make it clear the team
will be providing this support throughout the withdrawal /withholding process
Finishing an ICU family conference about end-of-life care
Achieve common understanding of the disease and treatment issues.
Understand patient beliefs, values and wishes
Make a recommendation about treatment with reasonable goals in context of patient’s
beliefs, values and wishes (as expressed through their substitute).
Ask if there are any questions.
Ensure basic follow-up plan and make sure the family knows how to reach you for
questions.
Useful Quotes (from Quill et al. 2001)
Clinical Scenario
Quote
Delivering very bad news
I wish I had better news to give you.
Responding to unrealistic hopes from a
patient or family
I wish that were possible. It sounds like all of us would be a
lot happier if that were so.
Responding to expressions of loss, grief,
and hopelessness
Responding to disappointment in medicine
or the physician
I wish it hadn’t turned out this way.
Responding to demands for aggressive
treatment when the prognosis is very poor
It must be very hard to come to the intensive care unit every
day and see so little change. I wish medicine had the power
to turn things around
I can understand how disappointing this is for you. I too wish
we had been able to do more for your mother
References for Workshop Material
Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pichora D, Shortt S, Tranmer J, Lazar N,
Kutsogiannis J, Lam M, et al. What matters most in end-of-life care: perceptions of seriously ill
patients and their family members. CMAJ 2006; 174(5). DOI:10.1503/cmaj.050626.
Teno JM, Fisher E, Hamel MB, Wu AW, Murphy DJ, Wenger NS, Lynn J, Harrell FE Jr. Decisionmaking and outcomes of prolonged ICU stays in seriously ill patients. J Am Geriatr Soc 2000; 48
(5 suppl):S70-4.
Heyland DK, Rocker GM, O'Callaghan CJ, et al. Dying in the ICU: perspectives of family
members. Chest 2003;124(1):392-7.
Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P, Le Gall JR, Schlemmer
B. Half the families of intensive care unit patients experience inadequate communication with
physicians. Crit Care Med 2000; 28:3044-9.
Carstairs S, Beaudoin GA; Subcommittee to Update “Of Life and Death” of the Standing Senate
Committee on Social Affairs, Science and Technology. Quality end-of-life care: the right of every
Canadian. Final report. Ottawa: Senate of Canada; 2000. Available:
www.parl.gc.ca/36/2/parlbus/commbus/senate/com-e/upda-e/rep-e/repfinjun00-e.htm
(accessed 2006 Nov 1).
A controlled trial trial to improve care for seriously ill hospitalized patients: The Study to
Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA
1995:274:1591-9.
Moreau D, Goldgran-Toledano D, Alberti C, Jourdain M, Adrie C, Annane D, Garrouste-Orgeas
M, Lefrant JY, Papazian L, Quinio P, Pochard F, Azoulay E. Junior versus senior physicians for
informing families of intensive care unit patients. Am J Respir Crit Care Med 2004; 169:512-7.
Tulsky JA, Fischer GS, Rose MR, et al: Opening the black box: How do physicians communicate
about advance directives? Ann Intern Med 1998; 129:441–449.
Teno J, Lynn J, Wenger N, Phillips RS, Murphy DP, Connors AF et al. Advance directives for
seriously ill hospitalized patients: effectiveness with the patient self-determination act and the
SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences
for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997 45:500-7.
Becker KL, Rose LE, Berg JB, Park H, Shatzer JH. The effectiveness of Standardized Patients. J Nur
Educ 2006; 45(4): 103-111.
De Champlain, A.F., Clauser, B.E., Margolis, M.J., Klass, D.J., & Nungester, R.J. (1998). Assessing
decision consistency with a sequentially administered large-scale standardized patient
examination: A Monte Carlo investigation. Academic Medicine,73(10 Suppl.), 78-S80.
Fallowfield L, Jenkins V, Farewell V, et al. Efficacy of a Cancer Research UK communication skills
training model for oncologists: A randomised controlled trial. Lancet 2002; 359:650–656.
Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after
discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 2001; 29:197201.
LeClaire MM, Oakes JM, Weinert CR. Communication of Prognostic Information for Critically Ill
Patients. Chest 2005; 128:1728-35.
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES: A six-step
protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;
5:302–311.
Back AL, Curtis JR. Communicating bad news. West J Med. 2002;176:177–180.
Lautrette A, Darmon M, Megarbane B et al. A communication strategy and brochure for
relatives of patients dying in the ICU. NEJM 2007; 356:469-78
Curtis JR, Patrick DL, Shannon SE et al. The family conference as a focus to improve
communication about end-of-life care in the intensive care unit: opportunities for
improvement. Crit Care Med 2001; 29(suppl):N26-33.
Quill TE, Arnold RM, Platt F. “I wish things were different”: expressing wishes in response to
loss, futility and unrealistic hopes. Ann Intern Med 2001; 135:551-5.
Appendix B:
Ethical/Legal Points about Capacity and Decision-Making in the ICU
Key Points from the Ontario Health Care Consent Act (1996):
1.
2.
3.
4.
All patients are assumed to be capable until you have a reason to think otherwise. In order to be capable of
consent for a procedure, a person must (1) be able to understand the relevant information for that
procedure, and (2) be able to foresee the consequences of a decision (or lack of a decision). (Section 4)
a. Capacity can change over time and depending on the treatment in question (e.g. a patient may
be capable to consent to simple Rxs like IV insertion but not to surgery)
b. A plan of treatment (e.g. a Rx plan that would include not performing CPR) is considered a
treatment under the Act and requires consent from a capable patient or their substitute
decision-maker.
A Patient’s or SDMs’ consent can be said to be informed, if they have been told:
 a description of the procedure or treatment;
 the likelihood of receiving benefits from the treatment;
 whether the treatment is necessary or elective;
 whether there is an urgency to the treatment;
 the likelihood of the risks associated with the treatment actually materializing;
 a health practitioner’s recommendation as to whether or not the treatment should be given;
 any information that the patient specifically requests
If a person is deemed incapable and a substitute decision-maker
Ranking of SDM (Section 20)
(SDM) is required, then the highest-ranking person who is
1. Guardian (Court appointed)
available, capable (ability to understand and appreciate as
2. Attorney
described above) and willing becomes the SDM.
3. SDM Appointed by Consent
a. If the SDM is not willing available or capable, the next
and Capacity Board
SDM on the hierarchy can be engaged in decision4. Spouse or partner
making process
5. Child or custodial parent
b. If more than one SDM of the same rank is available, they
6. Non-custodial parent
all have equal decision-making power and must all agree
7. Brother or sister
.
8. Any other relative
c. Clinicians cannot choose between SDMs of the same
rank. If there is disagreement between SDMs, the Public Guardian and Trustee can be called in to
make decisions OR the equal ranking SDMs can apply to the Consent and Capacity Board and can
argue why they should be designated as THE sole SDM
SDMs must make decisions based on (Section 21):
a. A prior known capable wish of the patient .
i. This must be expressed after age 16, applicable to the circumstances, and not
impossible to be carried out.
ii. These are interpreted by the SDM, not the physician.
b. If no prior capable wish is known, they must act in accordance with the patient’s best interests.
This judgment involves considering:
i. Beliefs and values of the patient that would influence their decision-making.
ii. Any statements that don’t meet the standards described above.
iii. Whether the treatment being offered:
1. whether the treatment is likely to improve the incapable person’s condition or
well-being;
2. whether the treatment is likely to prevent the incapable person’s condition or
well-being from deteriorating; or
3. whether the treatment is likely to reduce the extent to which or the rate at
which the incapable person’s condition or well-being is likely to deteriorate;
4.
c.
whether an incapable person’s condition or well-being is likely to improve,
remain the same or deteriorate without the treatment;
5. whether the benefit the incapable person is expected to obtain from the
treatment outweighs the risk of harm; and
6. whether a less-restrictive or less-intrusive treatment would be as beneficial as
the treatment that is being proposed.
If there is a dispute about whether or not the SDM is making decisions appropriately, the
clinician can file a Form G Application to the Consent and Capacity Board (CCB) for a hearing. If
they feel that the SDM is not making decisions according to Section 21, they can either give
direction to the SDM or substitute their own judgment for that of the SDM.
i. Rulings of the CCB can be appealed to the Ontario Superior Court
Bottom Line:
1.
Physicians in Ontario cannot legally withhold or withdraw life-support without consent from the patient or an
SDM, unless life-support would be considered outside the standard of care.
i. There is no widely accepted standard of care for futility.
ii. Any unilateral WDLS/WHLS can therefore be challenged according to CPSO policies, or in
civil or criminal court.
2. There are rules governing how an SDM makes decisions. They must follow the previously expressed wishes of the
patient (as long as they are not impossible), or make decisions based on statements or beliefs of the patient
balanced against the anticipated effects of the treatment on the person’s health and well-being (including pain
and suffering).
3. Physicians do not make the final decision about whether or not an SDM is following their instructions under the
HCCA. If you think that an SDM is exceeding their authority, you need to apply to the Consent and Capacity
Board for a “Form G” hearing.
Appendix C:
Brief Descriptions of Scenarios
1. Intractable Conflict. The trainee will meet with the son and daughter of a patient with endstage cancer who is deteriorating in the ICU. The patient may have previously expressed
wishes not to undergo aggressive life-sustaining therapy, but her family is adamant about
continuing with aggressive measures.
2. Discordance between SDM and Advance Directives. The trainee will meet the family of a
man with advanced cancer who had a clear advance directive not to receive aggressive lifesustaining measures. When he became too sick to speak for himself, part of his family
reversed his decision and insisted on admission to the ICU. The family is now divided about
how to proceed.
3. Grief and Inner Conflict. The trainee will meet with the daughter of a man with pancreatic
cancer who has suffered some significant postoperative complications and is now
deteriorating with an extremely poor prognosis. His daughter is overcome with grief about
the current situation and cannot decide whether to agree to ICU care.
4. Conflict Between Two SDMs of Equal Rank. The trainee will meet with the niece and
nephew of a patient with a severe stroke. The siblings have long been estranged from one
another and are now fighting about the plan of treatment based on their own values.
Scenario #1: Intractable Conflict
Take-Home Points
Objectives:
By the end of this scenario, participants should be able to:
1) Demonstrate skill in ongoing communication and negotiation with families who have been in the
ICU for a period of time and have had previous discussions with the ICU and other healthcare
teams.
2) Demonstrate skill in discussing withholding and withdrawal of life sustaining interventions and
CPR.
3) Demonstrate knowledge of ethical and legal issues surrounding withholding and withdrawal of
life-sustaining interventions and demonstrate their implications re communication with families.
4) Defuse anger and belligerency using communication/mediation techniques.
Legal/Ethical/Communication Points:
1. The family’s wishes are clear. The key here is to get at the patient’s wishes. You receive
new information from Colleen, but how does this information constitute a true “prior
competent wish”?
2. Even if you are sure that the children are not acting in their mother’s best interests, that
is not for you to judge. You would need the Consent and Capacity Board to decide this.
3. Be careful about repeatedly addressing the same issue and asking the same questions to
the children. This tends to escalate a conflict.
4. Conflict is always bad. It increases stress and frustration among HCPs, and it worsens the
grief and emotional trauma for the family.
5. Be aware of your own responses, attitudes and beliefs and how these may escalate
conflict (in particular be aware of your responses to a professional well-educated family
and the biases you may have that can contribute to frustrations and conflict).
6. Avoid matching anger and arguments. Your job is to diffuse tension. Listen to the family
and understand why they are angry.
7. Mediation involves certain principles:
i. Ground rules- One person speaks at a time, no intimidation or threats.
ii. Clarify what is being said. Illuminate the concerns/beliefs under the anger.
Identify commonalities.
iii. Identify underlying dynamics/sentiments, previous experiences, etc.
iv. Acknowledge emotions- allow them to be expressed.
v. Repeat and reframe. “What I’m hearing is…”
vi. Find a shared purpose.
8. Sometimes no matter what you do, no matter your level of skill, conflict cannot be
resolved by you alone or by the ICU team.
Scenario #2: Patient-Family Discordance
Take-Home Points
Objectives:
At the end of this scenario, participants will be able to:
1. Clearly establish who is acting as the substitute decision maker for an incapable patient.
2. Ensure that this person is fulfilling their role as defined by the Health Care Consent Act.
3. Resolve a situation in which a substitute decision maker is not acting according to the
wishes of the patient.
Legal/Ethical/Communication Points:
1. This case is simple and straightforward. The family has reversed a very clear desire on
the part of the patient not to be resuscitated or taken to the ICU.
2. Assess SDMs’ decision-making: are they following expressed wishes, best interests?
What role are their personal beliefs playing and how do you discuss this in practice with
them.
3. Explore with the SDM whether there is reason to believe that these wishes had
changed. If not, then the family is obliged to follow the wishes of the patient.
4. There are good and bad ways to communicate this obligation to the family. Try to be
supportive and understanding. Do not use shame or blame.
5. The PGT and CCB can be SUPPORTIVE here rather than antagonistic. They can clarify
points of dispute, without escalating a conflict.
6. In cases where a clear order is in place, you do not need to refer the decision to the
family, but it is always best to proceed with consensus. Remember that the CCB can
provide a ruling in a very short period of time.
Scenario #3: Grief and Inner Conflict
Objectives
By the end of the scenario, the participants should be able to:
1. Tactfully discuss the goals of critical care in a patient with advanced aggressive
metastatic disease with an acute complication.
2. Demonstrate skill in discussing withholding and withdrawal of life sustaining
interventions and CPR.
3. Demonstrate knowledge of ethical and legal issues surrounding withholding and
withdrawal of life-sustaining interventions and be able to explain them to family
members.
4. Ensure that the SDM is fulfilling his/her role as outlined in the Healthcare Consent Act.
Legal/Ethical/Communication Points
1. Remember that the relevant question here is what the patient would have wanted. Has
he made any statements specifically about this eventuality?
2. If he has not specifically talked about this eventuality, then you need to help his wife
make a decision based on his “best interests”. For this, you need to know:
a. Has he made any statements at all about ICU/aggressive care?
b. Is the proposed treatment likely to change the overall outcome, improve the
patient’s condition, or prevent or slow their deterioration? Does the expected
benefit outweigh the risk of harm (i.e. physiological harm as well as suffering)?
3. In this situation, a trial of therapy and withdrawal of life support are both reasonable
plans of treatment. You should be prepared to make a recommendation (if you have
one), but you must present both options as valid, and support the decision.
4. It is difficult to make good decisions when you are extremely emotional from grief. Use
active listening and basic humanity to defuse the grief and provide support.
Scenario #4: Conflict within a family
Take-Home Points
Objectives
At the end of this scenario, the participant should:
1. Understand the legally defined role of the substitute decision-maker (SDM) in the ICU,
and be able to explain it tactfully to a family member.
2. Mediate a dispute between two SDMs of equal standing.
3. Determine why two family members might disagree about the best course of action.
Ethical/Legal Points:
1. What would the patient want? Despite the poor anticipated outcome, it appears that
she would have wanted to pursue curative therapy anyways.
2. Be careful about splitting. Do not reinforce the division between “factions” inside a
family. Two SDMs of equal rank must both be involved in decision-making.
3. Can explore how they are arriving at what they think is the best decision and try to
mediate between them to achieve consensus on a treatment plan. A trial of treatment
with set goals may help resolve the situation
4. You cannot choose between SDMs of equal rank. Either the PGT has to step in and take
over decision-making (which they rarely do) or the SDMs have to apply to the CCB to
have one appointed above all others. Be careful regarding how your own personal
beliefs and your responses to the SDMs may influence your response to this situation.
Appendix D: Evaluation Forms
Ethical/Legal Pre- and Post-test for Participants
Trainee Identification Number:_______________________
Please indicate whether the following statements are TRUE or FALSE according to Ontario Law.
1. Patients must demonstrate capacity before they can consent to a
procedure. They are not assumed to be capable.
True
False
2. Patients of any age can be capable of consenting to a procedure.
True
False
3. A physician does not legally require consent in order to withhold CPR
or life-support because withholding a procedure is considered a
“plan of action”, not a treatment.
True
False
4. If two substitute decision-makers (SDMs) of equal rank cannot agree
about a treatment decision, the physician must decide which one is
acting according to the patient’s previously-expressed wishes and
respect their decision.
True
False
5. If a physician feels that a SDM is clearly not acting according to the
wishes or best interests of the patient, they should disregard the
SDM and make decisions according to what a “reasonable person”
would decide.
True
False
6. Possible substitute decision-makers (SDMs) include all of the following EXCEPT:
a. Attorney for personal care.
b. A brother who hasn’t seen the patient for 20 years.
c. A close friend who has lived next door to the patient for over 50 years, and knows their
wishes in the event of a cardiac arrest.
d. Someone who has lived with the patient in a conjugal relationship for the past 3 years
but they are not married.
e. A partner from a same-sex relationship who has lived with the patient for 10 years.
7. In order for an SDM to be able to make medical decisions for a patient they must do all of the
following EXCEPT:
a. Be available to make a decision
b. Be capable to make a decision
c. Be willing to make a decision
d. Be certain that their decision is consistent with what the patient would have wanted in
the circumstance.
e. Be certain that the proposed treatment is not associated with significant risks.
8. Which of the following statements most accurately describes a “Form G Application” to the
Consent and Capacity Board (CCB) of Ontario?
a. A physician can submit a Form G application to the CCB if they feel that a patient is
requesting a futile therapy.
b. A physician can submit a Form G application to the CCB if they feel that a SDM is not
acting in the best interests of the patient.
c. A physician can submit a Form G application to the CCB if the SDM cannot decide whether
to consent to a proposed treatment.
d. A physician can submit a Form G application to the CCB if there is no SDM available for a
patient after a reasonable search.
e. A physician can submit a Form G application to the CCB if they need to perform an
emergency procedure and they cannot obtain the consent of an SDM.
9. Which of the following is the highest-ranking SDM?
a. The patient’s brother.
b. The patient’s father.
c. The patient’s daughter.
d. The patient’s husband or wife.
e. The patient’s roommate.
10. When making medical decisions for an incompetent patient, an SDM must first consider which
of the following factors?
a. The religious views of the patient.
b. The religious views of the SDM.
c. The best interests of the patient.
d. Previous statements made by the patient regarding similar circumstances when they
were capable.
e. Whether any legal repercussions would arise if the patient died as a result of their
decisions.
11. Which of the following considerations is NOT used to determine whether a proposed treatment
is in a patient’s “Best Interests”?
a. A patient’s religious beliefs.
b. Philosophical statements made by the patient (e.g. “Where there’s life, there’s hope.”)
c. Whether the proposed treatment will improve the patient’s health.
d. Whether there is a less invasive alternative to the proposed treatment.
e. All of the above are used to determine a patient’s “Best Interests”.
SFM/Facilitator Evaluation Form
(to Evaluate Individual Trainees)
Trainee Identification Number:
Date:
Name of Evaluator:
Role of Evaluator:
Physician
Scenario:
SP/SFM
Please rate the trainee in the scenario from 1-10 on the basis of the following statements:
(1- strongly disagree…5- neutral…10-strongly agree)
Item
The trainee’s manner put the family at ease
The trainee used a relaxed style
The trainee listened carefully to the family and allowed
time for them to explain their concerns
The trainee understood the family’s concerns
The trainee directed the interview effectively
The trainee showed empathy and support
The trainee used open and closed questions effectively
The trainee avoided medical jargon
The trainee incorporated the patient’s wishes into the
plan
The trainee treated the family with courtesy and respect
The trainee was honest and acknowledged when they
didn’t know an answer.
The trainee was non-judgmental
The trainee was professional
The trainee was constructive and appropriate when
refusing requests
If I became ill, I would like this trainee to take care of me
Overall, this trainee was a good communicator
1 2
3
4
5
6
7
8
9
10
What did the trainee do well?
______________________________________________________________________________
__________________________________________________________________
What needs to be improved?
______________________________________________________________________________
__________________________________________________________________
Did the trainee say or do anything that you feel should never be said/done?
______________________________________________________________________________
__________________________________________________________________