CANH for patients and families
Five things to know about the new clinically-assisted nutrition and hydration guidance from the British Medical Association and Royal College of Physicians
The British Medical Association (BMA) and Royal College of Physicians (RCP) have jointly published new guidance on good practice in making decisions to stop, start or continue clinically assisted nutrition and hydration (CANH) for adults who lack capacity.
We were part of the BMA-led expert group that developed this new guidance. It is consistent with the standards in our End of life care guidance. Here we explain five key points about the BMA/RCP guidance.
CANH is medical treatment to provide nutrition and fluids to very ill patients who can’t eat or drink. It involves different types of tube feeding. This might be a tube inserted through a patient’s nose (a nasogastric tube), a tube going directly into the person’s stomach (a ’PEG’ or ‘RIG’) or an infusion into a vein. CANH is not food or drink or nutritional supplements given by mouth.
The joint guidance applies to adults who lack capacity to make their own decision about whether to start, continue with or stop receiving CANH. Specifically where the patient has a prolonged disorder of consciousness and CANH is the main form of life-sustaining treatment. The guidance applies to patients who:
- are in a vegetative state (PVS) after brain damage from a sudden accident (eg head injuries from a road traffic accident)
- who are in a minimally conscious state (MCS) after a serious deterioration in their medical condition (eg Parkinson’s disease or after a stroke)
- You can find out more about which groups of patients this guidance applies to here. All decisions about patients in these situations must involve the person’s family, carers or other people who can give information about the patient and speak up on their behalf.
The Supreme Court made a ruling in July 2018 which changes part of the process for making decisions about CANH in England & Wales. It used to be a requirement that, when a patient is in PVS or MCS state, all proposals to stop or not to re-start treatment with CANH had to be reviewed by the court. Now these decisions do not need court approval, where a thorough decision-making process has been followed and there is agreement between the patient’s family and carers and the healthcare team that it’s not in the patient’s best interests to continue with CANH.
You can read more about what the court said in the legal section of the new guidance.
When an adult patient does not have the mental capacity to make a decision about a particular treatment, anyone who is making the decision for them must follow the legal framework in the Mental Capacity Act 2005. It sets out safeguards to ensure decisions respect the patient’s rights and take into account their wishes, preferences and values. This includes a requirement to consult family members and other people close to the patient. The focus of these conversations is on finding out about the patient’s background and what their priorities might be, and trying to agree what they would want to happen if they were able to make the decision.
There is a handy flowchart in the new guidance which shows the best interests decision-making steps.
The guidance makes clear that, in cases where CANH is in place, it cannot be withdrawn unless the decision-making process has been followed and everyone involved has agreed that stopping CANH is in the patient’s best interests. If there is disagreement between a patient’s family/carers and the healthcare team, then a second opinion from an independent clinician can help. The guidance explains when a second opinion should be obtained and how this can be arranged. It also explains about applying to the Court of Protection for a ruling in cases where disagreements can’t be resolved locally.
Where to get more information
The new joint guidance from the BMA and RCP including a quick reference guide can be found here.