Dilemma: Family conflict over end-of-life care
Three experts advise a GP caught between family members with opposing wishes
Communicate directly with the family and explore the conflict
The scenario indicates a gentleman who is at the end of life from a probable gastrointestinal malignancy. That being the case, the best strategy is palliative care to allow a dignified death at home.
The scenario implies a lack of mental capacity. However this should be formally confirmed. If capacity is present the patient’s wishes are paramount. If not, the GP should determine if there is a lasting power of attorney. The GP is the key decision-maker in clinical matters.
The GP should communicate empathetically but directly with the family and avoid euphemisms. For example: ‘I am sorry your father is very ill. It is possible that he could die. We need to consider what to do next.’ Explain clearly the futility of further investigation and treatment.
Explore the conflict by asking the son directly: ‘It helps us to understand why you want these tests and treatment, can you tell us your reasons?’ Often a plea for active treatment is a sign of distress in coping with the situation or an unrealistic expectation of medical intervention.
Confident leadership from the GP is essential here. Good GPs provide care even without a definite diagnosis, and can exercise best-interests care for the patient even if family conflict persists. A discussion with a consultant may back up your strategy.
Dr Mayur Lakhani is chair of the National Council for Palliative Care and a GP in Loughborough, Leicestershire
This patient needs a best-interests decision made for him
This situation highlights the benefits of advance care planning, because if the wishes of the elderly patient were known at a time when he had capacity, this difficult situation could be solved more easily.
In the ideal situation, he would have appointed a lasting power of attorney with responsibility for health and welfare. Failing that, an advance decision to refuse treatment, properly presented, would guide decision-making. Least powerful, but still useful, would be a preferred priorities of care document.
As this patient cannot communicate, he needs the best-interests decisions to be made for him.
The Mental Capacity Act requires you to consider the person’s expressed wishes and feelings, beliefs and values, and to take into account the views of others who have an interest in the person’s welfare - their carers and those appointed to act on their behalf.
Hopefully by discussing the situation with all involved, an agreed decision can be made in the patient’s best interests. Doctors have no obligation to offer futile treatments or investigations, but if there is still conflict I would also contact the Office of the Public Guardian. It is always wise to seek another opinion from an experienced medical colleague.
Dr Peter Nightingale is a GP in Lancaster with a special interest in palliative care
If the patient lacks capacity to consent, the GP can make the decision about investigations
You need to determine whether the patient has the capacity to consent. This is essential where any kind of physical intervention is being proposed and is done via the two-stage test for assessing capacity under the Mental Capacity Act 2005 (England and Wales). The patient lacks capacity to consent to the investigation if he is ‘suffering from an impairment of, or disturbance in, the functioning of the mind or brain’ which causes him to be unable to:
- understand information relevant to the particular decision being made
- retain that information
- use it to make the decision, or
- communicate that decision by any means (the functional test).
Lack of consent is sufficiently proved if the patient is assessed as being unable to do any one of these four things.
Assuming the patient lacks capacity to consent, and there is no limitation to the GP’s ability to make a best interests decision on the patient’s behalf (such as lasting power of attorney for health and welfare in favour of the patient’s son or daughter), the GP as decision-maker will work out whether or not an investigation is in his best interests.
Andrew Alonzi is a Mental Capacity Act training consultant