The divorced parents of a very badly injured soldier in your base hosp · Medical

9 The divorced parents of a very badly injured soldier in your base hospital refuse to be present together but each insists that only they can speak on behalf of their son. His brain injuries are such that he is not competent to consent to medical treatment. How do you resolve this?

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: The divorced parents of a very badly injured soldier in your base hospital refuse to be present together but each insists that only they can speak on behalf of their son. His brain injuries are such that he is not competent to consent to medical treatment. How do you resolve this?

• List the Issues that arise from the scenario.

• Identify Critical Information required and Assumptions to be made:

The main issue in this case is the inability of a patient with severe brain injuries to provide informed consent, compounded by the refusal of the divorced parents to both be present and speak on behalf of their son. Each parent insists that only they can make decisions for their child, creating a conflict in decision-making authority. Critical information needed includes the patient’s medical prognosis, the legal standing of the parents, and their relationship with the patient. Assumptions should be made about the roles of the parents as legally entitled representatives and the urgency of treatment decisions. The healthcare team must consider their professional duties to act in the best interest of the patient while navigating family disagreements.

Step 2 – ANALYSE

Patient: Healthcare professionals are obligated to act in the best interests of patients, particularly when patients are unable to consent due to their condition (WMA International Code of Medical Ethics, https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/). The key concern is determining how to balance the rights of the patient and the conflicting claims of the parents to represent the patient’s wishes. The patient’s right to self-determination is central, and the healthcare team must ensure that decisions are made that best reflect what the patient would have wanted, had they been capable of expressing their consent.

Clinical: The clinical aspect requires a careful assessment of the patient's medical condition and the urgency of providing treatment. Since the patient cannot consent, healthcare professionals must make decisions based on the patient's best interests, considering the severity of the injuries and the likelihood of recovery. If there is ambiguity about the patient's wishes, the healthcare team must rely on legal representatives (usually the parents) to make decisions on their behalf, as outlined in the WMA Declaration of Lisbon on the Rights of the Patient.

Legal: Legally, the next of kin or legally entitled representatives are responsible for providing informed consent when the patient cannot do so. If the parents are the legal representatives, their conflict must be resolved through negotiation or escalation to a legal authority if necessary. The healthcare team must also respect the patient's right to confidentiality, ensuring that only necessary information is shared with the parents (WMA International Code of Medical Ethics, https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/).

Societal/Military: From a military perspective, the ethical issue at hand is how to handle the conflicting demands of the parents while ensuring the patient’s best interests are prioritized. Healthcare personnel must navigate the legal and ethical complexities of decision-making in conflict situations, respecting the patient's dignity while ensuring that care is provided without undue delays. In cases of family conflict, escalating the issue to the hospital’s decision-making system or seeking legal advice is essential.

Step 3 – FUSE

• Summarise conclusions

• Insert citations to key reference sources for your analysis

• Determine the exact Decision(s) to be made

The conclusion is that healthcare professionals must act in the patient’s best interest, even when the parents are in conflict over decision-making authority. The healthcare team should ensure that one parent, or a legally recognized representative, is authorized to make decisions on behalf of the patient. If the parents cannot agree, the situation should be escalated to the hospital’s ethics committee or legal advisors to resolve the issue. The decision should always prioritize the best interests of the patient while adhering to legal standards and ethical guidelines regarding informed consent. The WMA Declaration of Lisbon and the WMA International Code of Medical Ethics both emphasize the importance of respecting patients’ rights and ensuring decisions are made in their best interest.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The decision is to allow the parent who is legally entitled to make medical decisions for the patient to do so. If there is an ongoing conflict between the parents, it is necessary to escalate the issue to a hospital ethics committee or legal counsel to ensure the decision is made in the best interests of the patient. This approach is justified by the WMA guidelines on patient consent (WMA International Code of Medical Ethics, https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/) and the WMA Declaration of Lisbon on the Rights of the Patient (https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests.). Residual uncertainty includes how the conflict between parents might affect the timeliness of treatment decisions, so it is essential to ensure that the issue is resolved as swiftly as possible.

Further issues for consideration:

• What if this was a child with some decision-making capacity (e.g. a teenager)? - see Jack Spades

• What if this occurred in a field situation outside the legal jurisdiction of your organisation? - see Queen Spades, 3 Clubs, 4 Clubs.

• What if the patient was an important candidate for a research trial?