GMC Guidance – End of Life Care
The General Medical Council (GMC) has published new guidance entitled “Treatment and care towards the end of life: good practice in decision making”. The guidance came into force on 1st July 2010.
The GMC recognises that doctors who are providing treatment and care to patients approaching the end of their life will often face decisions that are clinically complex and emotionally distressing. The guidance therefore aims to provide advice and information to doctors, in order to help them effectively address such ethical dilemmas.
Outlined below are some of the areas that the guidance covers.
The guidance begins by outlining some fundamental principles to be followed in providing end of life care and treatment, some of which are:
- Doctors must give patients who are approaching the end of their live the same quality of care as all other patients. Patients and those close to them must be treated with dignity, respect and compassion. A patient’s right to privacy and confidentiality must be respected.
- Decisions concerning potentially lifeprolonging treatment must not be motivated by a desire to bring about a patient’s death and must start from a presumption in favour of prolonging life.
- Doctors must work on the presumption that every adult patient has the capacity to make decisions about their care and treatment. If a patient’s capacity to make a decision may be impaired, a doctor must provide the patient with all appropriate help and support to maximise their ability to understand, retain, use or weigh up the information needed to make that decision.
The guidance outlines two types of decisionmaking models that doctors can adopt, depending on whether the patient has the capacity to make a decision for themselves or not.
If a patient does have capacity, then the doctor must identify which treatments are clinically appropriate and explain these options to the patient. The guidance outlines what should happen if a patient asks for a treatment that the doctor considers would not be appropriate for them.
If a patient does not have capacity, then the decision making model is more complex and the Mental Capacity Act will apply. In essence, a decision must be made on behalf of the patient as to which treatment will provide overall benefit to them. The guidance states that it is important for the doctor to consult with the patient’s carers and relatives in such a situation. It explores the issues of patient attorneys and what powers they may have in relation to the patient; advance decisions or directives refusing treatment and how these should be recorded and communicated; and the role of Independent Mental Capacity Advocates.
The guidance goes on to explore the decision making models in more detail, and provides advice for putting them into practice. For example, it identifies the fact that disagreements may arise between the doctor and those close to the patient, or between the doctor and other members of the healthcare team, and suggests ways of resolving such disputes. It highlights the importance of advance care planning, and suggests matters that a doctor should discuss with a patient whose death from their
current condition is a foreseeable possibility. It provides advice on what a doctor should do if a patient is not ready to think about their future care or finds the prospect too distressing. It also explains what a doctor should do if their own personal beliefs lead them to object to complying with a patient’s decision to refuse treatment, or a decision that providing treatment is not of overall benefit to a patient who lacks the capacity to decide for themselves.
Neonates, children and young people
The guidance explains that decisions about treatment for children and young people must always be in their best interests. The guidance explores the concept of “best interests” and warns that identifying the best interests of children or young people who may be approaching the end of life can be challenging. The doctor should take into account clinical considerations, the views of parents and other factors relevant to the circumstances of each child. It may be appropriate for a doctor to seek advice or a second opinion.
The guidance goes on to explore when a child is capable of consenting to an investigation or treatment, and when a parent or the court can consent on the child’s behalf. It explains how a doctor can assess capacity and what should happen if a child lacks capacity to consent. It also provides practical advice on how to resolve disagreements over what course of action would be in a child’s best interests.
Clinically assisted nutrition and hydration
The guidance explains that nutrition and hydration provided by tube or drip are regarded in law as medical treatment. It also explains that unconscious and semiconscious patients may experience distressing nutrition or hydration by drip. It therefore explores when this type of treatment should be provided and how decisions in this regard should be made. It also discusses the disagreements that may arise over providing nutrition and hydration by drip, and suggests how these can be resolved.
Cardiopulmonary resuscitation (CPR)
The guidance explores the following in relation to CPR: l How and when decisions about CPR should be discussed with the individual patient.
- When a doctor should consider making a “Do Not Attempt CPR” decision.
- What should happen when a doctor has doubts as to whether the burdens and risks of CPR would outweigh the benefits to the patient.
- What should happen when a patient lacks capacity to make decisions about future CPR.
- How to record and communicate decisions about CPR.
- What should happen in an emergency situation.
The guidance can be found on the GMC’s website.
This briefing is for guidance purposes only. RadcliffesLeBrasseur accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.