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Conversations for ethically complex care

A framework to support discussion and documentation of decision making for levels of care in clinical practice.

Discussing the available options for treatment and care with patients is part of everyday clinical practice. When the options are evidence-based and available, and patients are clear about their wishes, decisions are often straightforward.

Decisions regarding the escalation, de-escalation or a change of level of care can be much more complex. They may be contested, highly contextual, or take place in the context of resource limitations over which the clinical team or organisation has no control. The patient, their family, carers and healthcare staff themselves may find the proposed changes challenging to accept.

This guidance provides a framework for ethical discussions to support decision making and documentation in clinical practice. It outlines a structured, patient-focused approach suitable for use by all professional groups, specialties and in all care settings. It is intended to be disease- or diagnosis-agnostic and to ensure fair and equitable care for all, without causing harm to their long-term health and wellbeing.

The accompanying Ethical Care Decision-Making Record (ECDMR) has been designed for use in more complex situations. It facilitates a discussion about care and assists with the recording of information, discussions and decisions. The ECDMR can be adapted for local use, and can guide structured clinical recording.

Please note that there will be circumstances where this approach is not appropriate. There may be situations beyond the scope of this process that require external expert and/or legal intervention and judgement.

Please send us your feedback

These are the first versions of the guidance and ECDMR. We are now conducting research on how helpful the ECDMR is in practice so we can continuously improve it.

We welcome feedback from doctors, which is vital for this project. Please send comments of any length and detail to policy@rcplondon.ac.uk.

We would also like to speak to doctors about their experiences using the ECDMR in practice. If you would like to take part in a short interview, please also email us via policy@rcplondon.ac.uk.