General Medical Council
Regulating doctors, ensuring good medical practice
Matthew Cohen is 53 and was diagnosed with Motor Neurone Disease (MND) 12 months ago. Six months after diagnosis he made a written advance decision to refuse certain treatments, including antibiotics in the event that he had a severe chest infection that might threaten his life. Mr Cohen had signed the statement and it was witnessed. He had given a copy of the statement to his GP and Respiratory Consultant to place on his medical records and also to his wife.
Mr Cohen collapses and is brought into the Emergency Department late one night. He is confused, feverish and mildly dehydrated. He is not able to communicate with the ambulance team or the Emergency Department team.
Dr Philips, a Senior Registrar in the Respiratory team, is on duty and is asked to see Mr Cohen. Dr Philips diagnoses the cause of Mr Cohen’s collapse as a severe chest infection that could be successfully treated by antibiotics and fluids but is uncertain whether to proceed because of Mr Cohen’s advance refusal.
Mr Cohen’s wife, Sharon, is at the hospital and explains that while her husband was initially adamant that he didn’t want to live with MND, he has in recent months been coming to terms with his illness and is looking forward to the birth of their first grandchild in 4 months time. They have also booked a holiday to visit friends in France at the end of the year. While his symptoms are getting worse, she is adamant that he would want to receive treatment for a reversible chest infection at this time.
This is the first time Dr Philips has treated a patient with an advance decision to refuse treatment but he is aware of the law relating to medical treatment of patients who lack capacity. He believes that Mr Cohen’s advance refusal is not valid because of the information from his wife that suggests a change of mind in recent months. Dr Philips checks the relevant sections of the Act’s Code of Practice on the Office of the Public Guardian’s website to make sure he has taken into account all of the relevant criteria in deciding if Mr Cohen’s advance refusal is valid and applicable to the circumstances.
In order to reassure himself that he is acting reasonably, Dr Philips also speaks to his on call Consultant, Dr Sharma, by telephone. Dr Sharma discusses the steps Dr Philips has taken to assess the validity and applicability of the written advance refusal and the factors he has taken into account. She agrees that, on the basis of what Dr Philips has said, it would be reasonable to conclude that Mr Cohen’s views had changed and that, as a result, his advance refusal of antibiotics for a chest infection was not valid.
Dr Philips provides fluids and antibiotics to Mr Cohen who responds well over night. Dr Philips’ reasons for not acting on Mr Cohen’s written refusal are recorded in Mr Cohen’s records. Two days later Dr Philips has a discussion with Mr Cohen and his wife and Mr Cohen agrees that he feels differently now and will make an appointment with his GP to revise his advance care plan and reconsider his advance refusal which he still wants to apply when he is much closer to the end of his life.
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.
The benefits of advance care planning (Paragraphs 50-55)
Supporting patients to formalise their advance wishes (Paragraph 60)
The importance of advance care plans being recorded and shared with those providing care and across different services (Paragraphs 61-62)
The reasons why patients like Mr Cohen may choose to make an advance decision to refuse treatment in particular circumstances (Paragraph 67)
What Dr Philips should do to decide whether Mr Cohen’s advance refusal is valid and applicable (Paragraphs 68, 70-71)
The importance of Dr Philips documenting the reasons for not following Mr Cohen’s advance refusal (Paragraph 74)
The need to review and update advance care plans as the patient’s situation or views change (Paragraph 62).
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