Table 3.

– Case examples of non-offers of care interventions at the end-of-life in 49 (52%) medico-legal cases with a patient/SDM allegations and expert opinions

Interventions Not Offered	Case Examples
Cardiopulmonary Resuscitation (CPR)	Allegation: an SDM agreed that cardiopulmonary resuscitation (CPR) would be harmful but questioned why the patient was not offered other treatment options. Clinical details: there was a moral distress among ICU staff regarding medical management of a patient. The critical care team felt it inappropriate to pursue CPR or re-intubation. After a meeting with the SDM, a physician wrote the DNR (do not resuscitate) order. Expert opinion: a peer expert opined the DNR decision was necessary and appropriate but was critical of a physician for failing to document a contemporaneous note outlining the details of the DNR discussion.
Pharmacotherapy	Allegation: an SDM alleged inappropriate use of pharmacotherapy and deficient monitoring of a patient’s respiratory status Clinical details: a post-operative patient developed somnolence and respiratory depression. Because of a pre-existing “DNR” order, the patient was not intubated. There was also a delay in initiating continuous positive airway pressure (CPAP) and the patient’s respiratory distress progressed to cardiac arrest. Expert opinion: a peer expert opined that a more detailed scope of treatment discussion would have added clarity, and the physician should have recommended intubation and recognized that this treatment was inconsistent with patient’s directive.
Admission to an ICU	Allegation: a patient’s SDM alleged a patient was denied admission to an intensive care unit. Clinical details: a physician discussed with a patient and their SDM that intensive care admission would be unlikely to allow the patient to survive. The patient did not want to be transferred to ICU and comfort measures became the clinical focus. Expert opinion: a peer expert found the care provided was reasonable and delivered with compassion.