The General Medical Council advises that patients’ wishes or those of their immediate families should be carefully considered when the time comes to make decisions about end-of-life care.
A hospital doctor may have to choose whether to perform cardiopulmonary resuscitation on an elderly patient, or a GP may have to decide whether to admit a dying patient to hospital or to keep him comfortable at home.
This is a different issue from that of assisting suicide and in many ways it is more challenging. To help a patient end his life, either by providing a prescription or personally administering a fatal overdose, is an active process, but one in which the patient has played a pivotal role. Deciding to withhold treatment from patients who may not have the capacity to refuse it for themselves is a medico-legal tightrope.
A doctor is expected to take all reasonable steps to prolong life. There is a presumption that he will act this way but there is no absolute obligation to do so. The final judgment rests with the doctor but he should be prepared to justify whatever decision was taken.
Patients who have the ability to decide for themselves should have their wishes respected. A written advance directive is invaluable but could be rendered ineffective if the patient has not discussed their wishes with the family.
Some patients lack the ability to express themselves, and the family's advice should be sought. Did the patient who is now comatose ever discuss how they would wish to be treated?
The crux of an advance directive is that it should be applicable to the current situation. It could be argued that a patient who signs a “Do not resuscitate” order and self-harms a few days later should be treated and then assessed for signs of an underlying and potentially treatable depressive illness.
If a patient has a condition that might lead on to what the GMC euphemistically terms “mental frailty”, then they should be encouraged to consider what their wishes might be in future.
Patients have a right to live and die with dignity.
Dr Martyn Lobley is a GP in southeast London
