Table 4.

– Summary of case examples of the most common contributing risk factors from the 44 (47%) medico-legal cases with peer expert criticism (2018–2022)

Contributing Factors, N (%) of Cases	Case Examples
I. Communication breakdown with a patient/SDM, 26 (28.0)
- Family expectations regarding severity of a patient’s condition	A breakdown in communication occurred between a physician and a patient’s SDM when the family was still hopeful that the patient would recover despite being given a terminal diagnosis, and the involvement of palliative care. A breakdown in communication occurred when a patient’s diagnosis and prognosis had not been explained to the family or they did not understand the explanations. A physician did not inform a SDM of a patient’s urgent medical condition.
- Goals of care and resuscitation status discussions	A simple “DNR” order was too ambiguous; a more detailed scope of treatment discussion to clarify the patient/family expectations would have prevented a patient’s death. At a meeting with a patient’s spouse, a physician did not clearly explain that the patient was near the end-of-life. A family was unaware that a level 3 status did not include resuscitation in the event of cardiac arrest.
- Discontinuation of critical care or life sustaining interventions	A patient’s SDM did not perceive their conversations with a physician as compassionate or caring when the discussion involved the financial cost of critical care and the allocation of nursing resources. College stated their expectation that physicians always conduct discussions about withdrawal of life support in a sensitive manner. A patient’s family was upset when the patient was moved to a palliative care bed prior to discussion.
- Clinical care management options	A physician did not discuss the risks and benefits of anticoagulation therapy with SDM.
II. Documentation deficiencies, 21 (22.0)	Non-existent or poorly detailed notes about: - rationale for clinical decision-making - a patient’s status including prognosis and clinical progress. - the clinical management plans. - results of diagnostic investigations. - details of crucial discussions with patients and their SDMs - patient’s verbalized end-of-life wishes.