The following process is designed to fit the widest range of cases and may be individually tailored as circumstances require. Thus, some of the questions may not be appropriate in particular cases. It is intended as a guide for identifying and exploring issues whose examination may lead to a resolution of the issues which may be troublesome in a particular case. It can be used by either individuals or groups who may be involved in a case discussion. It is designed to move any discussion along so that the necessary breadth of issues will be examined without unduly dwelling on those which have been adequately discussed. Finally, it is devised to move discussions beyond merely producing clarification to generating resolutions, strategies for communicating outcomes, and generating appropriate documentation. The ultimate goal of the process is to promote the well-being of patients and the integrity of caregivers.

I. BACKGROUND - FACTS, VALUES, CAPACITY, INFORMATION.

 1. What is the issue which has generated this ethical examination?
 2. Medical Components.

 A. What are the medical facts?
 B. What is the diagnosis and prognosis?
C. How certain/probable are the diagnosis and prognosis?
D. What are the time constraints for decision-making?
E. What significant information still needs to be gathered?

 A. What does the patient/family know?
 B. What is the patient's/family's current level of experience with the matter at hand?
 C. What are the patient's wishes, values, beliefs, and priorities?  D. How do the patients's previous life choices provide a context for this current situation and the decisions being considered?
 E. What has been the patient's experience with the interventions being considered?
 F. What are the family's wishes, values, beliefs, and priorities?
 G. What is the patient's/family's previous level of participation in the current decision?
 H. At what level does the patient/family want to participate in the current decision?
 I. Of what level of participation is the patient/family capable (degree of competency or decision- making capacity)?

 A. What are the recommendations, values, beliefs, and priorities of the member(s) of the healthcare team?
 B. Who is responsible for making the therapeutic decision?
 C. Does(Do) the member(s) of the healthcare team have a special personal or professional interest in the outcome of the decision?

 A. Are there special legal considerations?
 B. Are there special considerations regarding hospital policy?
 C. Are there special considerations regarding the concerns of society at large?

 1. What treatment options are available?
 2. What benefits are realistically available for each option?
 3. What benefits might be remotely attainable for each option?
 4. What are the risks or burdens of the various options?
 5. What are the probabilities of the benefits, risks, and burdens involved?
 6. How do the benefits, risks, and burdens fit into the overall value context of the patient/family?
 7. Are any professional standards of the member(s) of the healthcare team which will be compromised by any of the options being considered?
 8. Do any of the options place the institution or society at large at risk?

 III. PROBLEM  OR DISAGREEMENT.

 1. Is there a disagreement about what is to be done?
 2. If there is no disagreement, what kind of support can be offered to those involved in the decision?
 3. If there is a disagreement, what is the nature of the problem or disagreement?
 4. What option does the patient want?
 5. What option does the family want?
 6. What option does(do) the member(s) of the healthcare team want?
 7. What option is desirable within the policies, priorities, and practices of the institution or society at large?
 8. What is the rationale for the options chosen in terms of the wishes, values, and beliefs of the parties
  involved, i.e., patient, family, members(s) of the healthcare team, institution, and society?
 9. How are the benefits, risks, and burdens for the parties involved to be weighed against each other?

IV. ETHICAL VALUES AND PRINCIPLES.

 1. What values are at stake in this case?
 2. What ethical principles, e.g., autonomy, beneficence, fidelity, and justice, are at stake in this case?
 3. What ethical principle(s) should govern this case?
 4. What ethical system governs this case?
 5. How does the patient's/family's choice of options fit into the principle(s)?
 6. How do the options chosen by the member(s) of the healthcare team fit into the principle(s)?
 7. Are there institutional/societal values which must be considered in this case within the context of the
  governing principle(s)?

V. RESOLUTION.

 1. Do the parties agree on the decision and only need clarification of issues and support in the decision-
  making process?
 2. If there is no agreement, is it possible for the parties to negotiate?
 3. What are the areas of commonality shared by the parties involved?
 4. What is the patient's limit of compromise?
 5. What is the family's limit of compromise?
 6. What is the limit of compromise for the member(s) of the healthcare team?
 7. What is the institution's/society's limit of compromise?
 8. In the absence of a compromise, whose decision finally governs?
 9. What is the decision of the authorized decision-maker?
 10. What are the reasons for the decision in terms of values and principles?

VI. STRATEGIES FOR COMMUNICATING THE RESULTS OF THE DELIBERATIONS.

 1. Who communicates the results of the deliberations?
 2. In what order among the interested parties is notification given?
 3. How detailed should the communication be?
 4. What support mechanisms need to be utilized as a follow-up to the deliberations?
 5. Should the services of a trained/skilled communicator be utilized to help interested parties process the
  results of the deliberations?

VII. DOCUMENTATION.

 1. Should the case deliberations be recorded in the patient's chart?
 2. If the deliberations are not recorded in the chart, how should they be recorded?
 3. Should special measures be taken to protect the patient's confidentiality?
 4. Should there be any special institutional follow-up to address the issues raised in this case?
___________________
Lawrence P. Ulrich, Ph.D.
©1996 Breckenridge Bioethics