Ethics, Professionalism and Communication
What the board tests
Consent and capacity, refusal, confidentiality, end-of-life decisions, error disclosure and culturally attuned communication in a busy ED.
Consent and capacity
- Valid consent needs capacity, adequate information and voluntariness. Capacity requires understanding, appreciation, reasoning and the ability to express a choice.
- Disagreement with your advice is not incapacity. Assess the specific decision, document the reasoning.
- Emergency exception: treat a patient who lacks capacity and needs urgent life-saving care, using the least restrictive option.
- Minors: consent from a guardian, except for emancipated minors or specific statutory situations such as sexual health or emergency care.
Refusal, confidentiality and end of life
- For refusal: confirm capacity, explain risks, explore reasons, offer alternatives, ensure follow-up, document thoroughly.
- Confidentiality exceptions: notifiable diseases, court order, public safety and serious risk to a named person; disclose the minimum necessary.
- A valid do-not-resuscitate order travels with the patient and should be honoured in the ED; a competent patient can refuse treatment, and relatives cannot override that.
- Open disclosure after a medical error: acknowledge, explain, apologise, describe what happens next, and record it.
Communication
- Breaking bad news with SPIKES: setting, perception, invitation, knowledge, empathy, strategy and summary.
- Use a trained interpreter, not a child or bystander. Respect religious practice around fasting, transfusion and autopsy; ask rather than assume.
- Professional boundaries: no personal social media contact, declare conflicts of interest, prescribe for family only within policy.
Worked example
A 45-year-old, fully oriented man with suspected meningitis refuses lumbar puncture and antibiotics. He can explain his diagnosis, the consequences of refusal and the alternatives, and applies the reasoning consistently. He has capacity, so you cannot treat over his objection; document the discussion, offer a second opinion and close follow-up, and escalate to a senior clinician for a further conversation rather than sedating him.
Traps
Equating refusal with incapacity; taking consent from the wrong surrogate when the patient has capacity; breaching confidentiality in conversation or on social media; ignoring a valid DNR order; obtaining consent without discussing alternatives.