Talking about death and dying

Revised guidance for UK-registered doctors, published by the General Medical Council in June, comes into force on 1 July. Treatment and care towards the end of life: good practice in decision making has been developed substantially from 2002’s Withholding and withdrawing life prolonging medical treatment.

The negative-feeling title of that guidance reflected the way it concentrated on one controversial aspect of care at the end of life, and the 88 pages (!) of the new guidance helpfully take a more comprehensive view.

I have always believed in the statement that the best clinical and ethical decisions in healthcare are taken as a consequence of ‘a dialogue between two experts; the doctor or nurse who is an expert in her own specialty, and the patient who is an expert in two things – how he feels and what he wants’.

This guidance rightly seeks to give the patient-expert much more say in his treatment towards the end of his life, even if it sometimes has the potential to undervalue the doctor-expert’s contribution.

Doctors are urged in the guidance not to make assumptions about patients’ choices at the end of life. By encouraging doctors to listen to patients and their families, they are given much more voice in this vital clinical and ethical dialogue.

Advance care planning, the role of palliative care, acting on advance requests and refusals, assessing whether treatment is of overall benefit for patients who lack capacity, and discussing potential organ donation are all covered.

At Christian Medical Fellowship we particularly welcome the emphasis throughout on the 'presumption in favour of prolonging life', and that because conscience is important doctors can abstain from being involved in withdrawing clinically assisted nutrition and hydration if they believe it would be morally wrong.

However, given that the GMC had to reflect legal changes such as the 2005 Mental Capacity Act's requirement to comply with 'valid and applicable' advance refusals of clinically assisted nutrition and hydration (patients saying ‘no’ to the assisted provision of food and fluids even though foreseeably that might accelerate their deaths), the guidance may well cause problems for doctors who in a particular situation believe they are being forced to practise in a way that is clinically inappropriate or morally wrong. Although detailed advice is given about resolving conflicts in such circumstances, this aspect has the potential to create serious difficulties.

Since discussion of them began, CMF has always strongly opposed giving advance refusals legal force, but the fact is they are now here to stay. We have opposed them because they can introduce conflict into difficult clinical situations.

They risk forcing doctors to practise with one hand tied behind their backs, more mindful of avoiding prosecution or dismissal than of providing the best possible care. There is also the potential they could be used against patients by those with an interest in their deaths, on the grounds that 'it is what they wanted'.

However, having emphasised this concern, CMF further welcomes the fact that publishing this comprehensive guidance helps break the taboo on discussing death and dying. This taboo currently plagues both the healthcare professions and the general public.

Economically speaking, we can guarantee that resources for the NHS are going to diminish just when prolonging life at all costs in an increasingly elderly population requires ever increasing expenditure. As doctors we know that prolonging life at all costs is not always the best medicine; and of course as Christians we have the confident hope of eternity to offer.

Dr Andrew Fergusson is a former GP who is now Head of Communications at Christian Medical Fellowship. www.cmf.org.uk