When substitute decision-makers reject patient wishes and medical advice

It is important to recognize that where conflicts occur among the advice of physicians, the wishes of patients and the demands of substitute decision-makers, the issues are often greatly obscured by the emotion of the moment. Staff should therefore be alert to any indication that such problems might occur in order that appropriate steps can be taken to resolve these issues before they result in a major conflict. The key to this process is good communication between everyone concerned. There should be a clear understanding of the prognosis and care plan amongst the care team members. In cases where the patient is not expected to live, there should be early counselling for both the patient and the family. This counselling should include a determination of patient and family wishes and expectations. It is also important that all of the relevant information be well documented on the patient's chart. This helps to ensure that the patient's wishes are respected and also furnishes proof that staff and the hospital have exercised appropriate care in determining how best to care for the patient.