CANH for doctors and healthcare colleagues including senior hospital management
Five things to know about the new clinically-assisted nutrition and hydration guidance from the British Medical Association and Royal College of Physicians
Making decisions about starting, withdrawing or continuing clinically-assisted nutrition and hydration (CANH) when it’s the primary life-sustaining treatment for an adult with a prolonged disorder of consciousness (PDOC) can be extremely difficult. The British Medical Association (BMA) and Royal College of Physicians (RCP) have jointly published new guidance on good practice in making these decisions.
The joint guidance applies to decisions about adult patients with PDOC who are receiving CANH, or where a question arises about whether to start or reinstate CANH. This will include:
- patients with progressive neurodegenerative conditions (e.g. Parkinson’s or Huntington’s disease)
- patients with multiple comorbidities or frailty which is likely to shorten life expectancy who have suffered a brain injury (e.g. a catastrophic stroke)
- previously healthy patients who are in a vegetative state (VS) or minimally conscious state (MCS) following a sudden-onset brain injury (e.g. a traumatic brain injury after a road traffic accident).
We were part of the BMA-led expert group that developed this guidance and we’ve ensured it’s consistent with our End of life care guidance.
The Supreme Court ruled in July 2018 that the withdrawal or discontinuing of clinically-assisted nutrition and hydration (CANH) for patients with a prolonged disorder of consciousness (PDOC) does not need court approval in England and Wales, where:
- professional and clinical guidance has been followed, including obtaining a second opinion where appropriate
- the legal requirements of the Mental Capacity Act 2005 have been followed
- the healthcare team and the patient’s family and others close to the patient agree that it’s not in the patient’s best interests to continue with CANH.
The Supreme court ruling doesn’t change the best interests decision-making process. It places more weight on making sure healthcare teams are supported to make decisions which are ethically and legally sound in a complex area of practice.
It’s important that families and carers, as well as the doctors and the healthcare team, understand the basis on which decisions can be made about stopping, starting or continuing CANH in the case of an individual patient.
The guidance gives helpful advice on how everyone involved in caring for a patient with PDOC can work together to reach the right decision for the patient, whether they’re being cared for in hospital and community settings.
The importance of carrying out careful best interests assessments is stressed throughout the guidance. This is a key requirement of the Mental Capacity Act 2005 but there is evidence that practice in this area can be variable. So the guidance provides detailed advice about best practice in carrying out best interests assessments, including how to ensure that families/carers and others are effectively involved in the process – in line with the requirements of the Act and its Code of Practice.
Second opinions are critically important in making decisions for patients with PDOC. Doctors are advised to take all reasonable steps to get a second opinion from a senior clinician. This will be someone who has experience of the patient’s condition but who is not already directly involved in their care. They don’t need to be a doctor but could, for example, be a senior nurse or allied health professional with the relevant skills and experience.
The guidance sets out the type of expertise that might be required and the level of ‘independence’ from the patient’s team which the clinician providing the second opinion might need to have.
The advice in the BMA/RCP guidance is intended as practical support for healthcare professionals to make good decisions in this complex and sensitive area of practice. Clearly it can be taken into account, as evidence about best practice, or where patients and families and others with an interest want to know what it’s reasonable to expect in this area. But it isn’t a rule book, and it’s not intended to set thresholds for GMC fitness-to-practise action.
Where to get more information
The new joint guidance from the BMA and RCP including a quick reference guide can be found on the BMA's site.