Standards › Standard 2A › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · GOV-SOP-002 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.9
At a glance
- Call the ethics contact; describe the question in one or two sentences.
- If the case is urgent, treat first; ask for advice when the patient is safe.
- Give the facts in summary, without identifiers, to the consultation.
- Record the advice you received and what the team decided.
- Ask the ethics contact to log the consultation.
- Stop and get help straight away if: the patient is at immediate risk. Treat the risk first.
1. Purpose
To describe step by step how a staff member or family asks for ethics advice and what happens next [EC].
2. Scope
| Applies to | Staff who ask for advice, the ethics contact, and consultation members |
| Locations | All services |
| When | Whenever an ethical dilemma arises in care |
| Does not apply to | Research ethics (SOP-N05) |
3. Definitions
| Term | Meaning |
|---|---|
| Ethics contact | The named person who receives and arranges requests |
| Consultation note | The written advice from the consultation |
4. Background
The policy sets the principle. This procedure sets the steps, so that anyone can use the route without needing to know who sits on the committee.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Requesting clinician | Describes the case; makes the decision | Clinical competence |
| Ethics contact | Receives request; arranges consultation; records advice | Trained contact |
| Consultation members | Give advice in writing | Ethics training (EC) |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Request form | Current version | Available on each ward |
| Consultation log (GOV-REG-003) | Current | Updated after each consultation |
7. Safety
- Do not include patient identifiers in writing outside the approved route.
8. Before you start
- Gather the facts, the patient’s wishes and any advance decision in the record.
9. Procedure
Step 1. Make the request.
- Call or email the ethics contact, or complete the request form.
- State the question and whether it is urgent.
Key point: Urgent requests are not delayed by the paperwork.
Step 2. Prepare the summary.
- Write a one-page summary: diagnosis, options, the patient’s wishes, the views of the family, and the question.
- Remove names and identifiers, using a case code.
Key point: A short summary lets members focus on the ethical question.
Step 3. Attend or send the case to the consultation.
- Attend the consultation, or send the summary if you cannot attend.
- Answer questions honestly, including what you do not know.
Key point: The consultation depends on accurate facts.
Step 4. Record the advice and decision.
- Record the advice and the team’s decision in the clinical record, without the ethics note, if the policy requires.
- Tell the patient and family what was decided and why, where appropriate.
Key point: The decision and its reasons belong in the record, so the next team knows.
Step 5. Log the consultation.
- The ethics contact enters the case on GOV-REG-003 within 5 days.
Key point: The log is how the route is shown to work.
10. Decision points
- If the advice is not followed, the team records the reason in the clinical record.
11. Special situations
| Situation | Action |
|---|---|
| Out-of-hours urgent case | Use the on-call senior clinician as the first contact; the ethics contact follows up next working day (EC). |
12. Escalation
- If the route fails or cannot respond, inform the chief executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Consultations completed within the time set | 100% | Monthly | Ethics contact | Escalate to chief executive |
| Log entries complete | 100% | Monthly | Ethics contact | Complete within 5 days |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Request and summary (case code only) | Restricted ethics file | the period set by the facility’s records policy years |
| Consultation log (GOV-REG-003) | Governance file | the period set by the facility’s records policy years |
15. Training
- Ethics contacts are trained (EC).
- Clinicians receive a short briefing on the route at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-POL-004 | Clinical Ethics Consultation Policy | Principle |
| GOV-REG-003 | Ethics Consultation Log | Log |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
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)