Working with doctors Working for patients

 

Introduction

Mr Hartley is very seriously ill and his condition is deteriorating. He is receiving nutrition and hydration through a nasogastric tube. Dr Graham assesses his condition and with advice from a colleague, concludes that Mr Hartley's death is imminent and believes that the clinically assisted nutrition and hydration is now causing more problems than it alleviates. She recommends that tube-feeding be withdrawn, with Mr Hartley being kept comfortable and pain-free over the remaining few days. However, Dr Pascoe does not agree.

(The story so far...)

Mr Hartley, who is 76 and has Alzheimer's disease, has been admitted to hospital with a bowel blockage and infection. Given the severity of his condition and his general frailty, it has been agreed that surgery would not be in his best interests and he is being treated with antibiotics.

Dr Pascoe

Dr Pascoe

I don't see why we should be withdrawing nutrition and hydration at this stage, Dr Graham. Surely it's part of basic care and something we should be providing to patients in the last few days of life?

Dr Graham

Dr Graham

There are concerns that when Mr Hartley's consciousness level rises, the tube has been causing him discomfort. His fluid output is dropping too.

Dr Pascoe

Dr Pascoe

But if we withdraw nutrition and hydration he'll die more quickly, won't he? I know we can keep him comfortable with mouth care and so on, but I would have real difficulty about stopping fluids in these circumstances.

Dr Graham

Dr Graham

It'll be a matter of hours now, days at most, whether we withdraw it or not. His underlying condition is in the final stages. At this point, it's a question of what we can do to help Mr Hartley die peacefully and with dignity. From what we know of his wishes, I don't believe he would want us to persist with treatments that aren't providing any benefit for him.

Dr Pascoe

Dr Pascoe

I just have a huge problem seeing food and fluids as a 'treatment'. It's basic nurture - it shouldn't just be stopped. I understand that you and the rest of the team think it's the best thing for Mr Hartley, but it would go against my conscience to withdraw it.

What should the doctor do...? (Select A,B or C)

A

Continue to care for Mr Hartley but make it clear that she has serious moral objections to the decision to stop clinically assisted nutrition and hydration (CANH)?

B

Ask not to be involved any further in Mr Hartley's care, provided that there is another clinician who can take over her role?

C

Refuse any further involvement in Mr Hartley's care?

Dr Pascoe

See what the doctor did

After further discussion with Dr Graham, Dr Pascoe asked if arrangements could be made for another member of the team to take over from her. A colleague was found to cover, and Dr Pascoe withdrew from Mr Hartley's care.
Nutrition and hydration were withdrawn with the agreement of Mr Hartley's son and daughter, and he died peacefully two days later.

References

79. You can withdraw from providing care if your religious, moral or other personal beliefs about providing life-prolonging treatment lead you to object to complying with:
a. a patient's decision to refuse such treatment, or
b. a decision that providing such treatment is not of overall benefit to a patient who lacks capacity to decide.

80. However, you must not do so without first ensuring that arrangements have been made for another doctor to take over your role. It is not acceptable to withdraw from a patient's care if this would leave the patient or colleagues with nowhere to turn. Refer to our guidance on Personal Beliefs and Medical Practice (2008) for more information.
(Treatment and care towards the end of life: good practice in decision making, paragraphs 79 - 80)

123. If a patient is expected to die within hours or days, and you consider that the burdens of providing clinically assisted nutrition or hydration outweigh the benefits they are likely to bring, it will not usually be appropriate to start or continue treatment. You must consider the patient's need for nutrition and hydration separately.

124. If a patient has previously requested that nutrition or hydration be provided until their death, or those close to the patient are sure that this is what the patient wanted, the patient's wishes must be given weight and, when the benefits, burdens and risks are finely balanced, will usually be the deciding factor.

125. You must keep the patient's condition under review, especially if they live longer than you expected. If this is the case you must reassess the benefits, burdens and risks of providing clinically assisted nutrition or hydration, as the patient's condition changes.
(Treatment and care towards the end of life: good practice in decision making, paragraphs 123 - 124)