End of Life

Question 1

If a person with capacity withholds consent, is it unlawful to treat them, even if it ends their life?

Answer 1

Yes - this can be difficult for doctors

Question 2

Case on Kerrie Wooltorton (aged 26):

Drank anti-freeze and called an ambulance. She had done
this previously (nine times) and had consented to treatment which saved her life. On
this occasion she had an advance decision (drawn up in the presence of a solicitor and
so in accordance with the law) stating that she did not want life-saving treatment but
only comfort care. She called the ambulance because she did not want to die alone and
in pain. Even though she had an advance decision this is not a case of a suicidal person
using an advance decision to ensure their death. She arrived in hospital conscious,
refused treatment and was judged to have capacity.

What problems may arise here?

Answer 2

• She has an untreatable emotionally unstable personality disorder
• Was depressed
• Presence of mental illness is NOT itself evidence of lack of capacity
• Mental health act allows for compulsory detention and
  treatment of patients who have capacity

Question 3

The Mental Health Act allows for compulsory detention and treatment of patients who have capacity. What does this mean?

Answer 3

A person with capacity can be treated against their will in order to prevent self-harm and suicide if they have a mental disorder.

The treatment must alleviate or prevent deterioration of their symptoms.

Question 4

Why was it potentially decided not to detain Kerrie and provide treatment?

Answer 4

Repeated attempts to treat her disorder had been

unsuccessful in preventing her suicidal behaviour - further treatment would be futile.

Question 5

Is complying with the refusal of treatment of a patient with capacity who has tried to commit suicide regarded as assisted suicide?

Answer 5

No

Question 6

Is assisting suicide legal?

Answer 6

No - illegal under section 2 of the Suicide Act 1961

Question 7

What is assisting suicide?

Answer 7

If they perform an act that

is intended to encourage or assist suicide or an attempt at suicide.

Question 8

What is physician-assisted suicide? How does this differ from active euthanasia?

Answer 8

Involves a medical professional prescribing a lethal dose of medication for a patient; the patient then self-administers the medication.

Active euthanasia: where a medical professional administers the lethal
dose of medication

Question 9

Is physician-assisted suicide legal?

Answer 9

No - although there have been numerous attempts to legalise physician-assisted suicide

Question 10

What problems arise when a patient requests information that could enable them to
hasten their death. E.g. when a patient asks how much of their opiate medication they would need to take in order to end their life.

Answer 10

Problem of honesty and patient autonomy.

Problem of encouraging assisted suicide.

Advising the patient about what would be a lethal dose need NOT constitute an intention to assist. But, it could be illegal for it does provide information that is helpful to a patient who wants to end their life, and assists them in that aim.

Question 11

How should a doctor act when a patient raises the issue of assisting suicide, or ask for
information that might encourage or assist them in ending their lives?

Answer 11

A doctor should ‘limit any advice or information [they give to a patient] to…an explanation that it is a criminal offence to encourage or assist a person to commit or attempt suicide’.

Question 12

What should be offered to patients contemplating death?

Answer 12

Palliative care to provide the patient with an alternative and help alleviate the symptoms that might lead the patient to prefer to die.

Question 13

When may you withdraw or withhold potentially life-prolonging treatment from a patient who lacks the capacity to make the decision?

Answer 13

GMC states: the presumption should be in favour of prolonging life which ‘will normally require you to take all reasonable steps to prolong a patient’s life.’

Question 14

When might it be in the patient’s best interest either not to have treatment provided or to have treatment withdrawn?

Answer 14

For example, providing mechanical ventilation provides benefit in that it keeps the patient alive
but if this simply prolongs the dying process then it is unlikely to be of overall benefit and in the patient’s best interest.

Question 15

Is clinically assisted nutrition and hydration (CANH) required as treatment or basic care?

Answer 15

Treatment - so should be provided only if it is in the patient’s best interests

Question 16

Is there a legal obligation to provide treatment that is not clinically appropriate and of overall benefit?

Answer 16

No

Question 17

Does a patient have a right to insist on receiving a particular treatment?

Answer 17

Autonomy and the right of self-determination do not entitle the patient to insist on receiving a particular medical treatment regardless of the nature of the treatment.

Although a doctor has a legal obligation to provide treatment, this cannot be founded simply upon the fact that the patient demands it.

Question 18

Does a decision to withdraw or withhold life-prolonging treatment if it provides no overall benefit need to be authorised by court?

Answer 18

No - these decisions are made every day in hospitals

Question 19

What is PVS?

Answer 19

Persistent Vegetative State

A state caused by damage to the brain resulting in a ‘lack of evidence of awareness of
the self or the environment, of interaction with others, or of comprehension or expression of language’

Question 20

Do patients in CVS need CANH to survive? Do they need artificial ventilation?

Answer 20

Yes

No - cardio-respiratory function is intact

Question 21

Case example:

Tony Bland was 18 when he suffered severe crush injuries at the 1989 Hillsborough disaster which left him in a persistent vegetative state. His parents and doctors wanted to withdraw his ANH and allow him to die. They petitioned the courts, wanting assurance that this would not be regarded as intentional termination of life.

Why was this case controversial?

Answer 21

Bland was not approaching end of life so could have lived for many years sustained by CANH

Decisions concerning potentially life-prolonging treatment must not be motivated by a desire to bring about the patient’s death.

Question 22

How was the decision in the Bland case reached?

Answer 22

The court found that:

• Continuation of CANH is not in the best interests, for he has no best interests of any kind
• Since there is no longer a duty to provide nourishment and hydration a failure to do so cannot be a criminal offence

CANH therefore provided no clinical benefit.

Question 23

What are the defining features of euthanasia?

Answer 23

1) There is an INTENTION to bring about the patient’s death
2) For the patient’s GOOD or in their BEST INTERESTS

i.e. the primary motive is to bring about the patient’s death for that patient’s benefit

Question 24

What is passive euthanasia?

Answer 24

Brought about by an omission to provide treatment

Question 25

What is active euthanasia?

Answer 25

Death brought about by a positive act (such as a lethal drug injection)

Question 26

Is euthanasia legal in the UK?

Answer 26

No

Question 27

When there is a clinical judgment that treatment would provide no overall benefit, the decision to withhold treatment should not be confused with passive euthanasia. Why?

Answer 27

The decision is not made because the doctor wants to bring about the patient’s death but because providing treatment would have no overall benefit

Question 28

If medical judgement is that CPR would be clinically futile, doctors are under no legal or ethical obligation to provide it, even if the patient (or their family) requests it.

What must be done though?

Answer 28

The decision must be discussed with the patient or
their family (at the patient’s request or if the patient lacks capacity), and the reasoning
behind the decision sensitively conveyed.

They should also be informed that they are entitled to a second opinion.

Question 29

In cases where the decision as to whether CPR would be beneficial is finely balanced, what should be determinative?

Answer 29

The patient’s wishes

Question 30

Is withdrawing life-prolonging treatment viewed as an act or an omission?

Answer 30

An omission

Question 31

How do some campaigners for legalisation of assisted dying claim that euthanasia is currently practised in the NHS?

Answer 31

In cases where strong opiates are given to relieve pain at the end of life - respiratory depression and sedation caused by opiates shortens the life of the patient

Question 32

What is the Doctrine of Double Effect (DDE)?

Answer 32

You may carry out an act that has a good (or morally permissible) effect and a bad (or morally impermissible) effect, and so a double effect.

Question 33

What are the conditions for carrying out an act with a double effect?

Answer 33

1. The bad effect is an unavoidable side-effect of trying to bring about the good
2. The good effect sufficiently outweighs the bad side-effect (known as the proportionality
   condition) i.e. when patient has a life limiting condition and will die soon and are suffering
3. You only intend the good effect

Question 34

What is the DDE classically discussed in relation to?

Answer 34

Providing opiates to relieve the patient’s symptoms but which may also shorten the patient’s life

ONLY IF the patient’s symptoms can only be managed or relieved by doses at this level and with this anticipated consequence

Question 35

Another example of DDE:

Surgical amputation to treat unbearable pain in a patient with a gangrenous leg and multiple co-morbidities such that their anaesthetic risk is so high that the anaesthetic is potentially life-threatening.

What is the good/bad effect?

Answer 35

Good: symptom relief and saving them from a potential death caused by sepsis

Bad: treatment itself has a foreseeable and high risk of causing death.

Proceeding would be justifiable on the basis that relieving the unbearable
pain outweighs the real and significant risk of death from the anaesthesia.

But it would not be permissible to proceed with surgery if you intended the patient’s death or regarded the potential death as a desirable outcome.

Question 36

What is continual deep sedation (CDS)?

Answer 36

The patient is sedated to the level of unconsciousness in
order to relieve their experience of symptoms, the symptoms are severe and there is no other way to relieve them. –> form of palliative care

Question 37

Can withholding CANH be justified by the DDE?

Answer 37

No - only can be justified in terms of lack of overall benefit