Week 2- Advance Decisions to Refuse Treatment and Advance Care Planning

Question 1

What is the advantages of ACP?

Answer 1

Planning ahead allows for care to be accessed safely, at the right time and with continuity of delivery

Can avoid the conflicts and tensions that arise between doctors, patients and relatives during emotionally fraught times

Can help in determining right course of action if capacity is lost

Question 2

What should the ACP discussion include?

Answer 2

Patient’s wishes, preferences or fears in relation to future treatment or care

Feelings, beliefs or values influencing the patient’s preferences and decisions

Family members, or others close to the patient or any legal proxies that the patient would like to be involved in decisions about their care;

Interventions that may be considered or undertaken in an emergency, such as CPR.

Question 3

Is the ACP legally binding?

Answer 3

ACP is not legally binding

Document is taken into account when deciding what is of overall benefit if patient loses capacity

Question 4

What are the 3 types of Advanced decisions?

Answer 4

• Advance requests for treatment
• Advance refusal of treatment
• Decisions about CPR

Question 5

Why might a patient make an advance request for treatment?

Answer 5

A patient may weigh up risks/benefits differently from healthcare professionals

Apatient may want treatment that healthcare professionals consider to be inappropriate

Apatient may therefore be worried that, if they lose capacity, treatment that they consider to be worthwhile will not be given to them

Question 6

Advance request for treatment

a) are they legally binding
b) is a Dr obliged to follow it?

Answer 6

a) Are not legally binding
b) Doctor is not required to provide a treatment simply because a patient askes for it, if the doctor does not think it is in the patient’s best interests.

But the doctor must be able to justify why it is not in the patient’s best interests

Question 7

If an advanced request for tretament cannot be ignored how should tx decision be made?

Answer 7

• Treatment decisions should be made on the grounds of providing overall benefit
  
  • Overall benefit depends upon patient’s wishes and preferences
• The Advance Request is evidence of these, so must be given weight
• When burdens and benefits are finely balanced, an Advance Request may be the deciding factor

Question 8

Advance Refusal of treatment- why may some people refuse?

Answer 8

Their concerns may relate to what is involved with specific treatments

Or further treatments/quality of life issues following the treatment.

Question 9

When is an advance refusal of treatment legally binding?

Answer 9

It is valid

It is clearly applicable to the patient’s current circumstances

If an Advance Refusal meets the requirements of the Mental Capacity Act (MCA), it must be respected in the same way that a refusal of treatment by a person with capacity would be.

Question 10

When is ADRT not valid?

Answer 10

The person has withdrawn the advance decision since making it.

Since making the decision the person has created a Lasting Power of Attorney for health and welfare giving someone else the authority to refuse or consent to the treatment in question.

The person has done anything that is clearly inconsistent with the advance decision remaining their fixed decision.

Question 11

What are the other requirements for a valid ADRT?

Answer 11

• Over 18yrs when decision was made
• Patient had capcity to make the decision at the time it was made
• Not subject to undue influence in making the decision
• Decision was made with adequete information

Question 12

Applicability of ADRT- what must is state

Answer 12

• Precisely what treatment is to be refused
• Circumstances when the refusal should apply
• May specify particular circumstances when the decision to refuse treatment should not apply

May not be applicable if there are reasonable grounds for believing that circumstances exist which the patient did not anticipate and which would have affected their decision if anticipated, for example any relevant clinical developments or changes in the patient’s personal circumstances since the decision was made

Question 13

When does the ADRT apply?

Answer 13

Will only apply at a time when the person lacks capacity to consent to or refuse the specific treatment.

Question 14

ADRT what format can they be in?

Answer 14

Can be verbal rather than written

Question 15

What are the criteria to refuse life sustaining treatment?

Answer 15

The decision must be written

The decision must be signed by the person making it

The decision must be witnessed

The decision must specify that the treatment is potentially life sustaining, that is death could result from the refusal

Question 16

Who’s responsiblity is it to make HCP aware of advanced decisions?

Answer 16

The person making the advance decision is responsible for making sure healthcare providers will become aware of it.

• Inform their relatives
• Ask for it to be recorded in their healthcare records
• Carry a card/wear a bracelet
• Provide their GP with a copy

But as a doctor you also have a role to play- eg: record decisions in patient records

Question 17

CPR recommendations is based on what?

Who can make it and who should be consulted?

Answer 17

Guidance depends upon likelihood of CPR being successful;

–If a doctor considers CPR will not be successful, he or she can make a decision that CPR should not be attempted but should inform/consult with the patient or their family;

–Where CPR may be successful a decision should be based on the balance of benefits and burdens of treatment in consultation with the patient (if capacity) or their family

Question 18

CPR recommendations- what else should be considered?

Answer 18

Should be made in the context of wider treatment decisions for the patient, what treatments should and should not be initiated if the patient is acutely ill and lacks capacity. That is within a holistic assessment treatment plan for that patient.

Question 19

LPA what are the criteria? What does this enable the LPA to do? What must the decisions the LPA makes be made in?

Answer 19

• Made when the person has capacity
• The person and the donee (LPA) must be 18 years or over
• The LPA must be registered with the Office of the Public Guardian (there is a fee for this)

The LPA has legal authority to make decisions, and must be consulted, on behalf of the patient

The decisions made must be in the patient’s best interests