Standards › Standard 2A › Policies
Policy · GOV-POL-004 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.9
At a glance
- Staff facing an ethical dilemma in patient care can ask for a consultation at any time.
- The consultation is confidential, timely, and non-binding; the treating team decides.
- Requests go to the named contact (or the committee), who arranges a consultation within the time set.
- Each consultation is recorded in the log with the advice given, without patient identifiers.
- Stop and get help straight away if: a patient is at immediate risk. Deal with the emergency first and ask for ethics advice afterwards.
1. Purpose
To give staff a usable route to ethical advice on difficult patient care decisions, so that they are not left to resolve these alone [E-006, EC].
2. Scope
| Applies to | All clinical and non-clinical staff, and patients and families who raise an ethical concern |
| Locations | All services at the facility |
| When | At any time an ethical dilemma arises in patient care |
| Does not apply to | Research ethics, which is covered by SOP-N05, and legal disputes, which go to the chief executive |
3. Definitions
| Term | Meaning |
|---|---|
| Ethical dilemma | A situation where values or duties conflict in a way that makes the right action unclear |
| Consultation | Advice from the ethics route. It informs the decision but does not make it |
| Ethics committee or contact | The named person or group who receives requests (committee terms set out in this policy) |
4. Background
Difficult decisions about treatment, withdrawal, capacity, and end-of-life care are often made under pressure. Access to independent advice reduces harm and supports staff. Criterion 2A.9 asks for a usable process, not a document alone.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ethics contact or committee chair | Receives requests, arranges consultation within the time set, records advice | Clinical ethics training |
| Consultation members | Give advice; declare interests; respect confidentiality | Ethics training (EC) |
| Requesting clinician | Describes the case, provides the information, and makes the decision with the team | Own professional competence |
| Chief executive | Approves the policy and reports on the consultation log | Executive leadership |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Request form | Current version; no patient identifiers needed | Available to all staff |
| Consultation log (GOV-REG-003) | Current | Updated after each consultation |
7. Safety
- Do not include patient identifiers in requests, unless the consultation needs them and the process is secure.
- Do not delay urgent treatment while awaiting ethics advice.
8. Before you start
- Check whether the matter is urgent. If so, treat first.
- Gather the clinical facts, the patient’s wishes and the relevant records.
9. Procedure
Step 1. Ask for consultation.
- Contact the named ethics contact by phone or email, or complete the request form.
- Describe the question, the clinical facts in summary, and the time pressure.
Key point: A clear question gets a useful answer.
Step 2. Arrange the consultation.
- The contact arranges a consultation within two working days for non-urgent cases, and the same day where delay causes harm (EC).
- Invite the requesting clinician, the patient or their representative where appropriate, and members with relevant expertise.
Key point: Timely advice is useful advice. Late advice is a delay.
Step 3. Hold the consultation.
- Set out the facts, the values at stake, the options, and the likely effects of each.
- Give advice in writing, with the reasons.
- Make clear the advice does not replace the decision of the treating team, the patient or the law.
Key point: The advice must be reasoned. A bare recommendation is not useful to the team.
Step 4. Record the consultation.
- Enter the date, the question (without identifiers), the advice given and the reasons on the consultation log (GOV-REG-003).
- File the written advice in the restricted ethics file.
Key point: The log shows the route is used and what it advises. It does not identify the patient.
Step 5. Review the route and cases.
- The governing body reviews the number and type of consultations each year.
- Update the policy or training where a pattern shows a need.
Key point: Patterns show where staff need training and where policy is unclear.
10. Decision points
- If the requesting clinician disagrees with the advice, the decision stays with the treating team within the law, and the disagreement is recorded.
- If the dilemma involves a child, or a patient who lacks capacity, follow the relevant legal pathway as well (EC).
11. Special situations
| Situation | Action |
|---|---|
| Patient or family request for ethics advice | Accept the request and route it through the same process. |
12. Escalation
- If the route is not available or not responding, inform the chief executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Requests responded to within the time set | 100% | Monthly | Ethics contact | Escalate to chief executive |
| Consultations recorded in the log | 100% | Monthly | Ethics contact | Complete record within 5 days |
| Staff who know how to request a consultation (sample) | 80% (EC) | Yearly | Quality lead | Briefing |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Consultation log (GOV-REG-003) | Governance file, without patient identifiers | the period set by the facility’s records policy years |
| Written advice | Restricted ethics file | the period set by the facility’s records policy years |
15. Training
- Ethics contacts and committee members receive training in clinical ethics (EC).
- All clinicians are briefed on how to request advice at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-SOP-002 | Ethics Consultation Procedure | Procedure in detail |
| GOV-REG-003 | Ethics Consultation Log | Log |
| SOP-N05 | Research Ethics and Human Subjects Protection | Research ethics is separate |
| CON-POL-001 | Patient Rights and Responsibilities | Patient rights in decisions |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. Timeframes and membership are EC decisions. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)