Knowledge

Basic ethical principles: autonomy, beneficence, non-maleficence, justice
Ethical and legal issues in decision-making for the incompetent patient
Difference between euthanasia and allowing death to occur: doctrine of double effect
Legal aspects of brain stem death diagnosis
With-holding and withdrawing treatment: omission and commission
Principles of management of the organ donor (according to national / local policy)
Decision-making processes for withholding and withdrawing life sustaining therapies including documentation and iterative review
Physiological changes associated with brain stem death
Common investigations and procedures undertaken in the ICU prior to organ harvesting
The limitations of intensive care medicine - expectations of what can and cannot be achieved
Preconditions and exclusions for the diagnosis of brain stem death
Role of national organ/tissue procurement authority and procedures for referral
Principles of delivering bad news to patients and families
Clinical, imaging and electrophysiologic tests to diagnose brain death
Responsibilities and activities of transplant co-ordinators
Local resources available to support dying patients and their families, and how to access them
Bereavement: anticipating and responding to grief
Cultural and religious practices of relevance when caring for dying patients and their families
Principles of pain and symptom management
Procedure for withdrawing treatment and support
Causes and prognosis of vegetative states
Causes of brain stem death
Responsibilities in relation to legal authorities for certifying death (e.g. coroner, procurator fiscal or equivalent), and reasons for referral
Cultural and religious factors which may influence attitude to brain stem death and organ donation
The value of autopsy (post-mortem) examination.
Procedure for completion of death certification

Skills & Behaviours

Consult and take into account the views of referring clinicians; promote their participation in decision making where appropriate
Perform and document tests of brain stem function
Liaise with transplant co-ordinators (local organ donation authority) to plan management of the organ donor
Consult and confirm findings of brain stem function tests with colleagues as required by local / national policy or as indicated
Monitor vital physiological functions as indicated
Document pre-conditions and exclusions to brain stem death testing
Recognise and rapidly respond to adverse trends in monitored parameters
Recognise when treatment is unnecessary or futile
Discuss end of life decisions with members of the health care team
Willing and able to communicate and discuss issues pertaining to end of life with patients and relatives
Discuss treatment options with a patient or relatives before ICU admission
Participate in timely discussion and regular review of 'do not resuscitate' orders and treatment limitation decisions
Differentiate competent from incompetent statements by patients
Relieve distress in the dying patient
Withdraw life sustaining treatment or organ support
Participate in discussions with relatives about treatment limitation or withdrawal
Aware of the emotional needs of self and others; seeks and offers support appropriately
Communicate effectively with relatives who may be anxious, angry, confused, or litigious
Explain the concept of brain stem death and organ donation clearly
Lead a discussion about end of life goals, preferences and decisions with a patient and/or their relatives
Obtain consent/assent for treatment, research, autopsy or organ donation

Attitudes

Establishes trusting relationships with and demonstrates compassionate care of patients and their relatives
Integrity, honesty & respect for the truth underpin relationships with patients, relatives and colleagues
Appreciates that the decision to withhold or withdraw treatment does not imply the termination of care
Values clear decision-making and communication
Acknowledges the consequences of the language used to impart information
Willingness to communicate with and support families / significant others
Respects the ideas and beliefs of the patient and their family and their impact on decision making (does not impose own views)
Respects the expressed wishes of competent patients
Respects the religious beliefs of the patient and is willing to liaise with a religious representative if requested by patient or family
Offers psychological, social and spiritual support to patients, their relatives or colleagues as required
Desire to support patient, family, and other staff members appropriately during treatment withdrawal
Recognises personal limitations, seeks and accepts assistance or supervision (knows how, when and who to ask)

Basic Sciences also underpin the competencies within this domain. These are presented in full in the Basic Sciences Syllabus.