General Medical Council
Regulating doctors, ensuring good medical practice
Sally Jackson is 49 and has Downs Syndrome. Twelve months ago she was diagnosed with breast cancer. She has been having chemotherapy and although she found the side-effects unpleasant and distressing, she continued with it because she thought it would cure her illness. However, recent tests have shown that the cancer has spread to other parts of her body and her condition is now terminal.
Dr Michaels is a Specialist Registrar in Oncology and has an appointment with Ms Jackson to discuss with her the options for her future treatment and care. Ms Jackson, who lives in supported accommodation, is accompanied to the appointment at the hospital by her support worker, Kim.
Dr Michaels explains the diagnosis to Ms Jackson, and tells her that there are two things they can do. She can have a round of radiotherapy which may shrink the tumour and extend her life but unfortunately will not cure her. It may also cause soreness and swelling, and will make her feel very tired. Or if she decides that she does not want radiotherapy, he can arrange for her to have specialist palliative care to control her pain and other symptoms, possibly at the local hospice. Dr Michaels tries to explain in straightforward terms what the radiotherapy will involve and what palliative care can do for her, but Ms Jackson does not seem to understand. She becomes confused and upset.
Dr Michaels asks Kim to explain the options to Ms Jackson in her own words. He then asks Ms Jackson what is upsetting her. Ms Jackson says she does not understand why he wants to give her treatment that will not make her better, and she does not want to leave her home. Kim tells Dr Michaels that Ms Jackson is usually very determined about doing things for herself but can take a while to grasp complicated situations, and hates being rushed.
As the decision does not have to be made immediately, Dr Michaels suggests that he give Ms Jackson and Kim some written information to take away, for Ms Jackson to read when she is less distressed. He gives them an easy-read leaflet which explains what a patient can expect when they have radiotherapy, together with some information about the local hospice. He also undertakes to contact Ms Jackson’s Macmillan nurse and ask her to visit and talk to Ms Jackson at home, when she has had time to digest the diagnosis and may feel less pressured than she does in the hospital environment.
The following week, the Macmillan nurse reports that Ms Jackson has decided that she does not want any more active treatment, and would prefer to go into a hospice when the time comes, but wants to stay at home for as long as she can.
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 Ms Jackson has capacity to make the decision in question (Paragraph 11)
Helping Ms Jackson to understand her options and make a decision (Paragraph 12)
Involving Kim and Ms Jackson’s Macmillan nurse in the discussion to help support Ms Jackson (Paragraphs 17-21, 22)
Not allowing assumptions about Ms Jackson’s learning disability to affect the treatment she is offered (Paragraphs 44 – 46).
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