Refusal of treatment and disagreement over care — branching viva

Opening (candidate)

My first move is to assess the risk of serious harm. This child is bleeding and deteriorating, so the refusal risks imminent death, which meets the harm-principle threshold. I would stabilise the child by treating in the child's best interests under the emergency doctrine, continue respectful engagement with the family alongside, escalate to my seniors and the ethics service, and seek a court determination for the ongoing dispute. [1] [3]

Branch A — The threshold principle

Examiner: What principle sets the threshold for overriding a parental refusal, and how does it differ from the best-interests standard? [1]

Candidate: The harm principle sets the threshold: clinicians respect parental authority until the refusal risks serious and likely harm to the child that is not outweighed by respecting the decision. The best-interests standard is the working guide to the child's welfare throughout the decision, but it is not a licence to override every refusal. Confusing the two leads to overriding too readily, or respecting harmful refusals for too long. [1] [2]

Branch B — Why not the clinician alone

Examiner: Once the immediate emergency has passed, who decides an ongoing settled refusal? [4]

Candidate: The court. Once the immediate emergency has passed, the authority to override an ongoing settled parental refusal belongs to the court, not to the clinician acting alone. The clinician treats in best interests under emergency authority where there is imminent serious harm, then seeks a court determination. The court is the legitimate arbiter because it protects both the child and the clinician. [4]

Branch C — A goals-of-care dispute

Examiner: Three months later the same child is in PICU with severe hypoxic brain injury and the parents demand full treatment the team judges non-beneficial. How do you proceed? [5]

Candidate: I would reframe this as unmet hope and inadequate prognostic communication, not parental unreasonableness. I would re-explore what the family most wants for their child, re-share prognosis honestly, seek a shared decision, offer a second opinion, and call a formal ethics consultation or mediation early. The randomised evidence shows ethics consultation reduces non-beneficial treatment and conflict. [5]

Branch D — An adolescent refusal

Examiner: If instead the child were a competent 15-year-old refusing her own treatment, how would your reasoning change? [6]

Candidate: I would assess her competence for this specific decision, weighted to the gravity and reversibility of the consequences. A competent young person's refusal of reversible care carries real weight, while a refusal of life-saving, time-critical treatment by a younger or less mature adolescent leans toward protection. The question shifts from overriding a parent to honouring an emerging autonomy while protecting the young person from an irreversible decision she may later regret. [6]

Close

Confirm the plan, document the refusal pathway factually and contemporaneously, arrange team debrief and clinician support, and preserve the therapeutic relationship by keeping the door open wherever it is safe to do so. [1] [5]