Advanced Decision and Advanced Care

Doctors are bound by professional and legal obligations in end of life decisions.  They may wish to be actively involved in discussing these issues and helping patients to draw up an Advance Decisions and Care Plan.  They may wish to witness the resultant documentation, but they are not required to ‘rubber stamp’ documents drawn up on the advice of another health care professional.  Relevant documentation should be filed and its existence flagged up in the medical records.

An adult patient with mental capacity may;

• make an Advance Decision (or Advance Directive / Advance Statement) to refuse treatment should they lack capacity in the future
• set general wishes and preferences about end of life care to be incorporated into an Advance Care Plan (or Statement of Wishes and Preferences)

If the patient loses mental capacity to consent or dissent to treatment a valid Advance Decision must be respected.  Previously expressed wishes and preferences must be considered in a ‘best interests’ judgement using the Statutory Checklist.  Requests for a particular medical treatment should be considered, but there is no requirement to give unnecessary or inappropriate treatment.

A general desire ‘not to be treated’ does not constitute a valid Advance Decision.

Ignoring a valid & applicable Advance Decision or a patient’s previously expressed wishes and preferences may result in legal proceedings.

Emergency treatment may be given in patient’s best interests if no valid or applicable Advance Decision exists and should not be delayed to look for an advance statement.

Life-sustaining treatment and Advance Decisions must be;

• in writing and signed by the author or someone directed to do so by the author in his/her presence
• signed in the presence of a witness
• verified by a statement, signed in front of a witness, expressly &  explicitly stating that it is to apply to the specified treatment “even if life is at risk”

Advance Decisions may not refuse basic care eg warmth, shelter, hygiene & the offer of oral food & water which should be provided in the patient’s best interests.

A written or oral Advance Care Plan is part of good clinical practice for patients at risk of cardio-pulmonary collapse. It is a voluntary process of ongoing patient centered discussion to be implemented when an anticipated deterioration of function occurs. Such a plan is not legally binding, but has ‘legal standing’ and must be considered when making a ‘best interests’ judgment if a patient lacks mental capacity.

Some patients may wish to donate a Lasting Power of Attorney so that a decision may be taken on their behalf in the event of a subsequent loss of capacity.

Further reading

You will find more information in this GMC publication Treatment and Care Towards the End of Life: Good practice in decision making