General Medical Council
Regulating doctors, ensuring good medical practice
Mr Wu, who is 73 years old, was diagnosed 18 months ago with pulmonary fibrosis, after developing a dry cough and breathlessness.
He had previously been quite active, playing golf regularly with his wife, Lee, and their adult children. Mr Wu understood that his condition might deteriorate over the next 2-3 years and was keen to spend as much time as possible with his grandchildren while he was still relatively well.
After a recent admission to hospital with breathing difficulties, Mr Wu expressed concern about his future health to the nursing staff, but was reluctant to discuss this when approached by Dr Reagan, the Respiratory Consultant.
Mr Wu’s symptoms worsened and tests showed his lung function had deteriorated. He was started on medications that stabilised his lung function, but left him with significant breathlessness requiring short burst oxygen to manage his symptoms.
Despite the treatment, Mr Wu’s condition continued to deteriorate and over subsequent months he required 3 hospital admissions. He told Dr Reagan that he was tired of going back and forth from hospital, and preferred to be at home with his family, but knew that his wife found it very distressing when he couldn’t breathe, and his care was taking its toll on her.
At home, he required oxygen 24-hours a day. His bed had been brought downstairs and with the help of his GP, a care package had been put in place which helped with his washing and dressing. The GP and community matron visited regularly and the community palliative care team were helping to ensure that his breathlessness and pain were effectively managed.
Dr Reagan visited Mr Wu at home, at his GP’s request. Mr Wu asked frankly how long he had left to live and Dr Reagan explained it was probably a matter of days to weeks. With Mr Wu’s agreement, the community team placed his name on their end of life care register, recording his strong wish to die at home surrounded by his family, if that was at all possible.
Days later, at 8pm on a Sunday evening, Mr Wu became quite distressed. He took large doses of medication for his breathlessness and pain, but continued to call for help.
As a result of the drugs and hypoxia he became quite confused. Mrs Wu called the out of hours (OOH) service who suggested calling an ambulance, but on Mrs Wu’s insistence, agreed that Dr Singh the OOH GP would visit. Dr Singh found Mr Wu to be distressed by breathlessness and unable to communicate.
He measured Mr Wu’s oxygen saturation and concluded that he needed to be admitted to hospital. Mrs Wu explained that if her husband was going to die, she knew he would prefer to be at home with her. She was clearly upset and the OOH service advised Dr Singh that there was a note on Mr Wu’s file saying he had a strong preference to die at home.
Dr Singh discussed the options with Mrs Wu. He explained that in hospital, they would be likely to be able control his symptoms more quickly and it might be possible to stabilise his condition and allow him to return home. However he understood Mr Wu’s preference to be at home and he could seek advice and support from the palliative care team about how to manage the pain and breathlessness and allow Mr Wu to die at home.
He explained that since Mr Wu couldn’t communicate his present wishes, he needed to make a decision and felt that, on balance, it would be best to try and care for Mr Wu at home. Mr Wu’s daughter arrived to support her family and Dr Singh phoned the out of hours palliative care team for further advice and to arrange for the team to attend.
All paragraph numbers in the vignettes refer to the GMC's guidance Treatment and care towards the end of life: good practice in decision making (2010). You can download the guidance here (486 kb, pdf) for reference.
Starting with the presumption that Mr Wu has capacity to make the decision in question; helping him to understand his prognosis and options for treatment and care. (Paragraphs 11, 14)
Advance care planning to encourage and support Mr Wu in thinking about what he might want to happen as his condition progresses, including his preferred place of care. (Paragraphs 52-57)
Recording and communicating Mr Wu’s wishes and preferences to others involved in his care. (Paragraphs 61, 75-76)
Involving and supporting Mrs Wu; sharing relevant information (using local systems) and working in partnership with the health and social care teams to provide effective care at home for Mr Wu. (Paragraphs 17-21, 22-23, 75-77)
When Mr Wu lacks capacity to communicate his current wishes, taking account of the views of his wife and other information about his wishes and preferences, to make a decision about what treatment and care would be of overall benefit to Mr Wu. (Paragraphs 12 13, 15-16, 24-26, 40-43)
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