Doctors' 'end of life' concerns revealed by MDU
Queries relating to advance decisions, ‘do not resuscitate’ decisions and Lasting Powers of Attorney are the most common reasons for doctors to seek advice from the Medical Defence Union (MDU) when providing care and treatment for patients at the end of their life.
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Publication date: 20 May 2010
As the GMC publishes Treatment and care towards the end of life1 today, the MDU has revealed it opened an average of six advice files each month involving members who had concerns about an aspect of end-of-life care. Concerns about treatment at the end-of-life also feature regularly in the 25,000 calls to the MDU's advice line each year.
The MDU's 'end of life' cases included:
- 27 files relating to advance decisions to refuse treatment, including several from members who wanted to know how they should decide if a patient had capacity.
- 23 files concerning 'do not resuscitate' decisions, including a number of complaints from patients' families who believed they should have been consulted.
- 13 files about lasting powers of attorney (LPAs). For example, GPs who had been asked by a patient to help in relation to an LPA form.
- Nine files about withdrawal of treatment, including artificial nutrition and hydration. Most of these were from doctors seeking advice about how to deal with disagreements between family members over whether withdrawal was in a patient's best interest.
MDU medico-legal adviser, Dr Emma Cuzner, said:
"Treating and caring for a patient towards the end of their life can raise some of the most difficult dilemmas for doctors, not least because patients' and families' emotions may be raw and there may be scope for misunderstandings on all sides.
"As the new GMC guidance makes clear, doctors have an obligation to ensure patients who are dying receive the same respect and standard of care as all other patients, while relatives and partners should be treated with understanding and compassion. In our experience, most doctors approach end-of-life care with great sensitivity but it is important that there is support and advice available to help them communicate with patients and families and resolve any disagreements about a patient's care and treatment."
MDU solicitor, Ian Barker, commented:
"While much of the GMC guidance sets out doctors' existing ethical and legal responsibilities, it's helpful to have this single point of reference. One aspect of the guidance which may be unfamiliar for doctors is the use of the phrase 'overall benefit' rather than 'best interests' to describe the ethical basis for decision-making in adult patients without capacity. The GMC says this is designed to ensure the guidance can be applied across the UK where the legal terminology and requirements differ.
"It may be helpful for to bear in mind that there will be one course of action which is in the patient's best interest and similarly only one course will be to the patient's overall benefit. Doctors who are unsure of how to proceed in individual cases may need to seek specific advice from their medical defence organisation."
The MDU has produced the following advice for members on caring for patients who are approaching the end of their life:
- It is important to talk to patients about their condition or prognosis even where it may be difficult or distressing for them. Patients may appreciate the opportunity to invite a friend or relative to be present during the discussion.
- You should establish with the patient what information they want you to share, with whom, and in what circumstances, which can help to avoid disclosures that patients might object to. This can also help to avoid misunderstandings with, or causing offence to, anyone the patient would want information to be shared with, such as close relatives or friends.
- Give patients adequate time to reflect and ask questions, and to change their mind. They should ideally be given the opportunity in advance to consider what arrangements they would like in the final stages of their illness.
- If patients make clear they do not want details about their condition or treatment, you should explain why you think they need to understand the options and try to find out why they do not want the information. If they still do not want know, you should respect their wishes as far as possible but explain what information you need to provide so they can give valid consent to treatment. When patients still insist they still don't want to know, the GMC says you should explain the potential consequences and make a note of their decision. You should also make it clear that they can change their mind at any time.
- The GMC expects you to plan ahead as much as possible. For example, it's important to discuss an advance care plan which would allow patients to indicate what treatment they would like if they lose capacity, or become unable to communicate their wishes effectively.
- Competent patients have the right to give, or withhold, consent to treatment and their wishes must be respected.
- Breaking bad news to relatives is always difficult as their anxiety may mean they do not take in all of what you are saying. Set out the information in a clear and simple way, explaining any complicated issues in lay terms and avoiding medical terminology. Ensure relatives have the opportunity to ask questions and discuss any concerns they may have.
- Note your discussion with patients and relatives in the patient's medical records.
Further information
- Treatment and care towards the end of life: good practice in decision-making, The GMC, 20 May 2010
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