From best interests to justified discretion: a process-based framework for emergency end-of-life decision-making

Abstract Background Emergency end-of-life decisions for patients who lack decision-making capacity may be required when prognosis, preferences, and surrogate input remain uncertain. Best interests provides a contested patient-centred orientation but may not identify a single clearly preferable option. This article examines how clinicians can justify unavoidable discretion under these conditions. Methods We use normative conceptual analysis of bioethical literature, professional guidance, and illustrative legal materials from Taiwan and England and Wales. The analysis examines best interests and threshold-based alternatives, distinguishes substantive interests from clinical judgment and justificatory legitimacy, and situates the proposed framework in relation to Accountability for Reasonableness. No empirical dataset was generated or analysed, and the literature was not assembled as a systematic review. Results The analysis distinguishes three levels: normative orientation, decisional judgment, and justificatory legitimacy. Five constraints—proportionality, reversibility sensitivity, professional coherence, urgency calibration, and good-faith justifiability—are operationalised through six steps: establish the decisional context; gather reasonably available patient-specific evidence; define substantively defensible options; apply the constraints; decide and document; and reassess when circumstances change. Hypothetical clinical illustrations demonstrate the pathway. The contribution lies in integrating established considerations for individual emergency end-of-life decisions, particularly prospective preservation of options and deliberation scaled to urgency. Urgency constrains the feasible process but does not justify substantively indefensible treatment. The framework has not been empirically evaluated for feasibility or effectiveness. Conclusions When patient-centred interests remain underdeterminate, ethical legitimacy requires clinical discretion to be supported by transparent, professionally defensible reasons responsive to uncertainty and changing circumstances. The framework complements substantive ethical reasoning and supports clinical, institutional, and judicial review without replacing professional judgment, Accountability for Reasonableness, or applicable law. Prospective qualitative and implementation research is needed to evaluate its practical use.