General Medical Council
Regulating doctors, ensuring good medical practice
Mrs Kadiri is 58 and a retired nurse. A week ago she unexpectedly suffered a serious stroke during heart-bypass surgery. She remains in an intensive care unit on mechanical ventilatory support with a breathing tube still in place.
Tests, including several electrocardiograms (ECGs) and an Echocardiogram (ultrasound) suggest that some further surgery might help improve her heart function.
The surgery carries significant risks because of Mrs Kadiri’s condition and it is unclear, if the operation is successful, whether she will recover sufficiently to be able to leave intensive care. However, without surgery, Mrs Kadiri would remain dependent on ventilation and other intensive care support, and would be at risk of developing other organ systems failure.
Mrs Kadiri has a large family who are constant visitors. The consultant, Dr Arya, asks to talk to the family about the next steps in treating Mrs Kadiri. At the meeting, Mr Kadiri explains that his wife has given him ‘a power of attorney’1 , in case anything should happen to leave her unable to decide for herself after the operation.
Dr Arya asks whether she can see the documents, and notes that Mrs Kadiri has specified that her husband can make decisions about life-sustaining treatments. She reminds Mr Kadiri that he must make decisions that are of overall benefit to Mrs Kadiri. She suggests a meeting where the options can be explored and the benefits, burdens and risks explained – by herself, another physician who specialises in treatment of stroke, and two of the nurses who have been providing care. She suggests Mr Kadiri invites other family members too.
At the meeting Mr Kadiri and his sons listen to the assessments of Mrs Kadiri’s conditions and prognosis, why she is unlikely to currently understand the situation and whether she is likely to recover functions, including speech, and the levels of pain and other discomforts arising from her treatment.
The potential risks of surgery are also explained, and the probable consequences if the operation is not done. They ask questions about clinical matters, and also ask the nurses their views on how well Mrs Kadiri is tolerating treatment and whether her breathing and circulation support are causing her any distress.
The family, particularly Mrs Kadiri’s sons, are distressed and overwhelmed by the situation and Mr Kadiri is hesitant about making a decision. Dr Arya reminds Mr Kadiri that he must consider what would be of overall benefit to his wife, bearing in mind his wife’s values and approach to life and how they would have affected her decision in these circumstances. Mr Kadiri asks Dr Arya whether he can take some time to consider all the information and they agree to meet the following afternoon. Mr Kadiri discusses the issues with the family, including Mrs Kadiri’s mother, and with the minister from his church. He reaches the conclusion that in the circumstances further surgery would not be of overall benefit to his wife.
Mr Kadiri is reassured by the team’s explanation of the steps they would take to ensure his wife’s comfort and dignity and to manage any pain or distressing symptoms, including removing any active intensive care interventions and removing any devices that were not of benefit and avoiding anything that might cause her distress.
It was also explained that if she remained relatively stable for many days, or even weeks, there would be support for him and the family to care for her at home, or in a hospice.
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.
Understanding the scope of Mr Kadiri’s legal authority to make decisions in relation to his wife’s treatment and care (Paragraph 15 (c))
Explaining the options to Mr Kadiri, setting out the benefits burdens and risks of each option; offering support to Mr Kadiri in making a decision but being careful to not pressurise him to make a particular decision (Paragraph 16 (d))
The information Mrs Kadiri’s sons and others close to her can contribute to help Mr Kadiri make a decision (Paragraph 16(e))
Recognising the emotional difficulties Mr Kadiri and his family are facing and supporting them in understanding Mrs Kadiri’s condition; helping Mr Kadiri to make a decision about his wife’s treatment and care (Paragraphs 33-36)
Supporting Mr Kadiri to weigh up the benefits, burdens and risks of the treatment options for his wife and to reach a decision about what course of action would be of overall benefit (Paragraphs 40-43).
1. In England and Wales this is a Lasting Power of Attorney; in Scotland a Welfare Attorney. There is no equivalent in Northern Ireland. Decisions must be made, in consultation with those close to the patient, on the basis of what is of overall benefit to the patient.
Close this window to return to the decision making flowchart.