The British Medical Association (BMA) and the RCP have today jointly published decision-making guidance for doctors on clinically-assisted nutrition and hydration (CANH) for patients who lack the capacity to consent.
The guidance, endorsed by the General Medical Council, follows a number of legal developments and aims to ensure the law is followed correctly and to give practical advice to health professionals about how to make these difficult decisions, based on what is in the best interests of the individual patient.
The BMA and the RCP have also produced an information booklet for healthcare providers and managers, and a guide for family and friends, outlining the key role they have to play in the decision-making process.
The guidance covers decisions in patients who lack capacity in England and Wales, who are not imminently dying and could go on living for some time if CANH – which by law is a form of medical treatment – is provided.
The broad spectrum of patients this guidance covers has been divided into three broad categories:
- patients with a progressive neurodegenerative condition
- patients with multiple comorbidities or frailty which is likely to shorten life expectancy, who have suffered a sudden-onset, or rapidly progressing, brain injury
- previously healthy patients who are in a vegetative state (VS) or minimally conscious state (MCS) following a sudden-onset brain injury.
Publication of the guidance follows the supreme court’s judgement in July in the case of Mr Y, which confirmed that there is no requirement for decisions about CANH to be approved by the court, provided there is no disagreement between the treatment team and the patient’s family and the law and professional guidance have been followed.
The guidance provides the most up-to-date statement of doctors’ professional and legal obligations, and provides in-depth advice about the process to be followed and the different factors for doctors to consider in making these decisions. In the absence of the involvement of the court, the guidance will provide vital support to doctors, while protecting patients and preserving public confidence.
While the starting point is a strong presumption that CANH should be provided, with the intention of prolonging life, at the centre of any decision is whether beginning or continuing treatment is in the best interests of the individual patient. The guidance lays out how these best interests assessments should be made, and the important role that patients’ families and those close to them play in the process. It also includes detailed information on seeking the necessary second opinion from another clinician when making these decisions.
It clarifies how health professionals must find out as much as possible about the patient from family and friends, in order to determine what the individual would want to happen in the situation that has arisen. If it is clear that the patient would, or would not, want CANH provided, this will usually determine their best interests.
