Best-interests decisions and treatment limitation — viva

Stem

Examiner-led viva on a disputed treatment-limitation scenario. [6]

Examiner: The team agrees intensive care can no longer help her. On what principle do you frame the recommendation? [1]

Strong answer: I frame it on the best-interests standard, which for a child who cannot decide for herself weighs the benefits of continued life-sustaining treatment against its burdens from her point of view. I weigh the chance of meaningful recovery against the cumulative suffering, loss of dignity and prolonged dying she is now bearing, and I bring a second senior clinician and the wider team to consensus before I bring a recommendation to the family. [1]

Examiner: The parents say stopping the ventilator is worse than never starting it. How do you respond? [4]

Strong answer: I explain that withholding and withdrawing life-sustaining treatment are morally equivalent — the consensus position is that there is no ethical difference between never starting a non-beneficial treatment and stopping one already begun. Treating them differently biases practice toward overtreatment. Stopping is not abandonment; it is an active comfort procedure with symptom relief and the family present, and comfort care is intensified, never withdrawn. [4] [9]

Examiner: They insist on full escalation and a miracle. Is this futility? [6]

Strong answer: I distinguish physiological futility, a factual claim that a treatment cannot achieve its goal, from a value dispute about whether the resulting quality of life is worth living. Here the team and family may broadly agree the prognosis is dire but disagree about the worth of the outcome — that is a value dispute, not pure physiological futility, so I do not declare futility unilaterally. I resolve it through shared deliberation, a second opinion, and ethics input. [6]

Examiner: You cannot reach agreement. What now? [12]

Strong answer: I escalate through an ethics consultation and mediation, and I consider a time-limited trial if any meaningful uncertainty remains. If consensus still cannot be reached, I seek a court declaration rather than overriding the family unilaterally or capitulating to indefinite non-beneficial treatment. Comfort care continues throughout. [1] [12]

Examiner: Could you have done anything earlier to prevent this deadlock? [5]

Strong answer: Yes. I would have held a ceiling-of-care and goals-of-care conversation between crises, not during one, so the plan was agreed and documented in advance. The window-of-opportunity logic applies to acute injuries, but for a progressive condition the equivalent is proactive advance care planning — agreeing what will and will not be offered at the next deterioration, documented so it survives a middle-of-the-night admission. [5] [1]

Examiner: One key pitfall to avoid? [4]

Strong answer: Treating an isolated 'not for resuscitation' entry as a complete limitation plan. A defensible plan documents what will and will not be offered across escalation, ventilation and comfort, and links the resuscitation decision to the broader goals-of-care plan rather than leaving it as a single order. [4]