This case-study looks at what to do when a patient is very ill and deteriorating. What should you do if you disagree with a colleague over when to remove tube-feeding?
The scenario can be viewed as an interactive story on the GMC website here - or you can read it in full below.
Narrator: 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 She recommends that tube-feeding be withdrawn, with Mr Hartley being kept comfortable and pain-free over the remaining few days.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.
Discussion between Dr Pascoe and Dr Graham
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: 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: 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: 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: 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.
Should the doctor (Dr Pascoe)…
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?
a. This might be in line with GMC guidance but is likely to be problematic for Dr Pascoe who may well feel she is being made to act against her conscience. It could also be distressing for those close to the patient if they are aware that there is conflict within the healthcare team.
b. This would be in line with GMC guidance. Guidance on conscientious objection refers specifically to objection on the basis of religious, moral or other personal reasons. Disagreement with a decision on a solely clinical basis should be approached in the same way as any other disagreement about care.
c. This would not be in line with GMC guidance, which emphasises that doctors must not impose their personal views on patients or leave them without care. Doctors with a conscientious objection may withdraw from a patient's treatment provided there is another clinician who can take over their role, so that patient care is not compromised.
What the doctor did
Narrator: 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 Clementine and Robert, and Mr Hartley died peacefully two days later.
Treatment and care towards the end of life: good practice in decision making paragraphs 79 – 80
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 123 – 124
Adult Patients who lack capacity and are expected to die within hours or days
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.
Dr Rosemary Leonard MBE is a general practitioner in South London. She qualified from Cambridge and spent several years training in obstetrics before switching to general practice in 1987. Dr Rosemary is currently resident GP to BBC Breakfast News and has columns in both Woman and Home magazine and the Daily Express.
In this section, Dr Rosemary talks about the ethical issues in Mr Hartley's case study.
"…assessing advance refusals of treatment…"
The right of a competent adult to refuse medical treatment, even if that refusal may result in their death, is well established in law. A valid and applicable advance refusal of treatment has the same effect as a refusal of treatment by a patient who has the capacity to make the decision.
Having said that, advance refusals may come in many forms, ranging from a generalised verbal refusal noted in a patient's records – as in Mr Hartley's case – to a detailed ‘living will' type document. It is for the doctor arranging care to assess whether the refusal is valid and applicable to the patient's particular circumstances.
"…working with those close to the patient…"
Family members, partners, carers and anyone else close to an incapacitated patient will often have strong opinions about the treatment and care they want their loved one to have. They may also often have information about what the patient would have wanted, if they could still speak for themselves. Problems can arise if, as in the case between Clementine and Robert, there are differences of opinion, about what the patient's wishes would have been.
While trying to manage such situations, it is important to start by establishing whether anyone has legal authority to make treatment decisions on behalf of the patient, if they lose the capacity to do so. Where, as is still often the case, there is no legal proxy, doctors must explain what they are asking those close to the patient to do – not to make a decision about treatment, but to provide an insight into the patient's wishes, views and values which will then inform the decision about treatment. Such discussions will never be easy, but clarity about the role of family members and others in the decision-making process may avoid or resolve disagreements that can add to distress at an already difficult time.
"…conscientious objections to stopping a life-prolonging treatment…"
Some doctors may (for religious or personal reasons) disagree in principle with patients' right to refuse life-prolonging treatment like clinically assisted nutrition and hydration. Some doctors may hold the view, as Dr Pascoe does, that food and fluids are not treatment but basic nurture and should therefore never be withdrawn.
While GMC guidance does not require doctors like Dr Pascoe to act against their beliefs, it does stress that they must not abandon such patients, nor allow their care to suffer. The care of patients must always come first, and doctors may, rarely, be required to set aside their personal views until another doctor can be found to take over their role.
This case-study is from the Good Medical Practice in Action section of the GMC websiteCase study - A doctor considers her moral objections Case study - A doctor considers her moral objections End-of-life-care: Withdrawing a feeding tube