"When to die? Who decides? A brief look frameworks for decision making."

1. "When to die? Who decides? A brief look frameworks for decision making." Case Studies and Questions Gianetta Rands, Consultant Neuropsychiatrist Chester, 24th November 2017

2. This is a seminar about life and death decisions. • Who makes them? • How do you feel about them? • As a responsible professional what would you do in that situation? • As a patient what would be your choice? • What do you think about the law relating to these decisions? • How do you balance risks and uncertainties?

3. Alan Bennett’s Talking Heads – A cream cracker under the settee • What has Doris done? • How do you feel about this? • If you had visited instead of the policeman, what would you have done? • Can you imagine making this sort of decision? • How would you feel if someone you knew was in a similar situation?

4. Guidance for clinical decision making • GMC Consent: Patients and Doctors making decisions together (2008) www.gmc-uk.org/guidance • - Guidance on good clinical decision making, informed consent, involving families/carers/advocates, advanced decisions, recording and reviewing decisions and • “Part 3: Capacity Issues” 2016 GMC Mental Capacity Decision Tool and Flow chart (back of handout) • Also: • - BMA guidance ‘Withholding and Withdrawing Life-prolonging Medical Treatment’ and ‘End of Life Care’ • - The Royal College of Physicians’ Guidance on Prolonged Disorders of Consciousness

5. MCA, 2005 (direct quotes from the Act; for reference) • S2 … “a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.” … permanent or temporary. • S3: For the purposes of section 2, a person is unable to make a decision for himself if he is unable— • (a)  to understand the information relevant to the decision • (b)  to retain that information • (c)  to use or weigh that information as part of the process of making the decision • (d)  to communicate his decision (whether by talking, using sign language or any other means). 
 • The more serious the decision, the greater mc required eg P may have mc to decide about tea/coffee or pink/blue jumper but not to choose between accommodation options.

6. S4: BI assessment means making decisions in P’s best interests • Consider all options available to P, even if seem unavailable eg to go home • P’s past and present wishes and feelings, any relevant written statements made when P had capacity • P’s beliefs and values • in consultation with named person(s), carers, LPA attorneys, deputies • P may regain capacity – will they agree with this decision? • Enable P to contribute to decision • If decision involves life sustaining treatment there must be no motivation to bring about the person’s death. Eg Beneficiaries. • LC372 reform of s4 recommends it becomes an ACTIVE duty of decision makers to ascertain wishes, feelings, beliefs and values of P and, have a duty to give particular weight to these in decision making.

7. S5 – Acts in connection with care or treatment how protected do you feel by s5, MCA? • If a person (“D”) does an act in connection with the care or treatment of another person (“P”), the act is one to which this section applies if— • (a)  before doing the act, D takes reasonable steps to establish whether P lacks capacity in relation to the matter in question, and 
 • (b)  when doing the act, D reasonably believes— (i) that P lacks capacity in relation to the matter, and (ii) that it will be in P’s best interests for the act to be done.
 • Amendments to s5: Care-givers are only not liable if there is a written record of decision making process that is compliant with the MCA

8. Can Courts make decisions that clinicians cannot make?Why can treating teams/doctors not make some of these decisions? • Consider Cases • C – refuses dialysis • B – refuses amputation • Mrs P disagreements about BI