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dame cicely saunders

Mr J is an 86 year old man with terminal heart failure and dementia – he develops a chest infection. Despite oral antibiotics and oxygen he steadily worsens and starts to refuse food and choke on fluids. The medical team have to decide whether to start intravenous fluids and intravenous antibiotics or start Mr J on the Liverpool Pathway for palliative care. Mr J’s daughter is keen that everything possible be done for her father including ventilation if necessary but his son says that his father had expressed a wish that if his quality of life worsened he would like to die.

This scenario can be looked at from the view point of all involved.

The patient’s point of view
If the patient has capacity [ability to understand his situation and the full implications of treating and not treating] his autonomy [right to decide about his own life] should be respected. He would have the right to decide the extent of his care and his condition should be discussed honestly with him.
If he has dementia and his chest infection may mean he becomes more confused than usual. However he may still have lucid periods during which his wishes should be explored.
His son said that in the past he had stated the wish to die if the quality of his life worsened. Is this adequate to constitute an Advance Decision [‘Living Will’]? Advance Decisions do not necessarily have to be written down.
Has a Lasting Power of Attorney been granted? A Lasting Power of Attorney gives the nominated holder the right to decide what happens to the patient. One needs to establish whether his son was given a Lasting Power of Attorney.

The son’s and daughter’s points of view
If a patient does not have capacity or has not given a Lasting Power of Attorney or made an Advance Decision, a family member can advocate on the patient’s behalf.
Relatives often disagree. It is the doctor’s duty to explain carefully the risks and possible advantages of treatments. Many interventions such as putting a naso-gastric tube to feed a patient are extremely unpleasant and relatives must be made aware of this. Doctors have been criticised for ‘frightening relatives’ because they tell them that if an elderly patient has full blown CPR after a cardiac arrest they are highly likely to suffer brain damage even if they survive – however that is true!
Some relatives confuse ‘doing everything’ with caring and may consider that to be proof that they care more than other siblings. End of life discussions are difficult and good communication skills and the ‘art of medicine’ really become important.
There should be an honest exchange of views and the doctor may well learn about the patient’s likely preferences [for example from the son’s comment]. However if no Lasting Power of Attorney was given a doctor has no obligation to do what the family request – just to take into consideration their views.

The doctor’s point of view
The doctor has to respect a patient’s autonomy but if the patient does not have capacity [or has given a Lasting Power of Attorney] a doctor has to act with beneficence [in the best interest of the patient]. It is generally considered by the medical profession and legal profession that sometimes treatments are ‘futile’. ie they extend life by very little, leaving the patient with a poor quality of life for the extra time gained. Doctors then have the right to withdraw treatments that may discomfort the patient and concentrate on keeping the patient comfortable to achieve quality of life rather than quantity.
However it is however impossible  to accurately predict such things as the ‘likely quality of life’ and when death may occur. ‘How soon Doctor?’ is a very common question relatives ask and one we really never know the answer to. Uncertainty is part of medicine.

Society’s view
Society on the whole accepts passive euthanasia – that is the withdrawal of treatment that may lead to death. But it at present rejects active euthanasia – treatment to cause death to relieve suffering. The difference between ‘mercy killing’ and ‘letting’ someone die’ is reflected in the law. Physician Assisted Suicide – ‘mercy killing’ [such as in the Tony Nicklinson case] is illegal but withdrawal of treatment that results in death such as in the Liverpool Care Pathway is allowed. As Tony Hope wrote the moral difference between ‘acts and omissions’ is ‘one of those simple, complex ideas’ that preoccupies much ethical debate and euthanasia [usually used to describe active euthanasia] is rarely out of the news.

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