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Table 1 Summary of the Decision-making framework

From: A bioethical framework to guide the decision-making process in the care of seriously ill patients

Step# and guiding ethical principle Main focus Goals Method Practical objectives
1st step: Ethics of Accuracy The body and its biology: the diseases and treatment options To be accurate in diagnosis, prognosis, and success and failure rates of possible treatments. Evidence-based practice, probabilistic and scientific reasoning To Present:
a) A correct diagnosis and the phase of the disease.
b) A probable prognosis, i.e., how the majority of patients with that phase of the disease will evolve over time.
c) The absolute risk reduction, the relative risk reduction, the number needed to treat.
The potential adverse effects as well as costs and inconveniences of treatments. Uncertainty is addressed through estimation of confidence intervals and the disclosure of the potential limitations of generalization of evidence in that specific case.
2nd step: Ethics of comprehension The person and biography: patient’s values and views of suffering. To comprehend and be empathetic to the patient’s suffering, respecting the other as an end in itself. The emphasis here is to listen, to be present and to learn about biography, not to act, to change or to fix it. Empathic communication To learn about the patient’s understanding, views, life values, perceptions of suffering and treatment preferences.
3rd step: Ethics of situational awareness The healthcare multidisciplinary team To apply the scientific evidence developed in populations to the specific situation of the patient, conciliating evidence based treatments with the patient’s values and biography. Clinical judgement and effective team communication A team proposal of which would be considered:
a) the acceptable evidence based treatment, taking on consideration the scientific view only
b) The best or recommended treatment following both the scientific evidence while also respecting the patient’s biography and wishes.
c) The potentially inappropriate treatments following scientific evidence and the patient’s biography and wishes.
d) The futile or unacceptable treatments, considering exclusively the scientific basis.
4th step: an ethics of deliberation The patient-provider relationship Establishing rapport and building consensual patient-provider goals of care, ensuring that the patient’s values will be respected and scientifically acceptable practices will be used. Deliberation and person-centered communication To have and honest and empathic communication about diagnosis, prognosis and then, to establish consensual goals of care for the best and worst scenario. After the setting of GOC, specific treatments within the Step#3 proposal are deliberated between patient and physician, reaching a new consensus about which treatments might or might not be employed to reach the desired goals.