Despite enormous advances in medical knowledge, technology and treatments that enable life to be extended when it might otherwise cease due to organ failure or disease, there is no overriding duty on a doctor to prolong life regardless of the effects upon the patient or against the patient's expressed wishes.
There is, however, a duty for the doctor to act always in the patient's best interests. Particular difficulties arise when the patient is unable to articulate those interests for him/herself, whether owing to handicap, immaturity or brain dysfunction resulting from injury or age-related disease.
The booklet Withholding and Withdrawing Life-prolonging Medical Treatment produced by the BMA Medical Ethics Committee is in the form of guidance, not guidelines, because each and every patient has to be considered uniquely. There are no algorithmic absolutes here, but the outline of a series of steps to be taken when these difficult decisions are being considered and the factors that should be addressed.
These fall into three groups – medical ethical and legal. They are discussed in relation to children, the competent adult and those who do not have the capacity to make decisions for themselves.
For all patients, the underlying principles of maximising benefit and minimising burden for the particular patient should guide decision making when the initiation or continuation of any form of treatment is called into question.
In general practice the withholding of treatment or the opportunity to access treatment is a more frequent problem than possible withdrawal.
A common example is the elderly patient who has previously often expressed the wish not to be admitted to hospital but to die in his/her own bed. Whether this is the expression of fear of the unknown or an indication of not wanting benefit-less extension of life may be uncertain, but it is a wish that the doctor has acknowledged and implicitly agreed
When the patient suffers a severe stroke and is unconscious, does the GP admit the patient to hospital knowing that this may mean an infusion while the situation is assessed? The patient's best interests for nursing care (as the family cannot cope) may be in conflict with their apparent wishes. When there is doubt, treatment must always be provided. It is essential that doctors, nurses and relatives communicate fully and understand each other.
Most patients on artificial nutrition and hydration are in hospital, but an increasing number are being discharged for ongoing nursing care in the community, especially into registered nursing homes under the care of GPs. Some of these patients have a nasogastric or PEG tube in situ on discharge and the dilemma may later arise when the continuing use of such a means of nutrition is causing distress with no apparent improvement in the patient's overall condition.
This guidance should help GPs who are unfamiliar with making decisions in such circumstances to address all of the factors involved. It will always be a difficult process.
Patients in the UK have the opportunity to develop an ongoing relationship with their GP, and often tell their GP things that they have not discussed with their family, particularly in the context of end-of-life issues, for fear of hurting their relatives.
GPs should listen carefully to what patients tell them, even when it does not appear relevant to the consultation in question, because the GP should be a participant in any later hospital-based decision-making process, although not a member of the multidisciplinary team directly involved in the ultimate decision.