Table 2.

– Summary of examples of the most common patient/SDM’s allegations from the 93 medico-legal cases

Allegations, N (%) of Cases	Examples
1. Communication breakdown between a physician and a patient/SDMa, 46 (48.9)	A physician:
	- Failed to speak to a patient directly to obtain their resuscitation status. - Did not include a patient/SDM in level of care discussions. - Wrote a “Do Not Resuscitate” (DNR) order without first having a discussion with a patient’s SDM. - Failed to inform a family of the patient’s admission to the intensive care unit (ICU). - Failed to discuss the decision to implement palliative care with the patient or explain what types of care were included in palliative care. - Involved the Consent and Capacity Board (CCB) to determine if an SDM’s decision was within the patient’s best interests.
2. Deficient assessment of a patient, 31 (33.0)	A physician:
	- Performed an inadequate assessment and reassessment of a patient’s condition. - failed to diagnose a patient’s condition in a timely manner. - Failed to immediately recognize the severity of the patient’s condition.
3. Unprofessional manner, 29 (31.0)	When:
	- An SDM felt coerced or bullied into changing the level of care for their parent. - A physician inadequately managed the privacy and care of a patient. - A physician communicated in a harsh manner and failed to show compassion and empathy.

^aCommunication issue with a patient, patient’s family, or substitute decision maker on the part of the healthcare provider, not the patient. This includes ignoring/dismissing patient concerns