1. Advanced Refusals of Treatment Millie Fern & Rachel Marshall E.C.Fern@warwick.ac.uk Rachel.Marshall@warwick.ac.uk

2. Learning objectives Describe the legal framework governing patients refusing life sustaining treatment and advance refusals of treatmentDescribe the legal framework governing patients refusing life sustaining treatment and advance refusals of treatment Describe current professional guidance on advance requests for treatment and advance refusal of treatment and the ethical principles that inform the guidanceDescribe current professional guidance on advance requests for treatment and advance refusal of treatment and the ethical principles that inform the guidance Relate current professional guidance on DNACPR decisionsRelate current professional guidance on DNACPR decisions Demonstrate awareness of the concept of Advance Care Planning and the legal distinction between this process and Advance Refusal of TreatmentDemonstrate awareness of the concept of Advance Care Planning and the legal distinction between this process and Advance Refusal of Treatment Recognise the contributions of different health and social care professionals in providing person centered end of life careRecognise the contributions of different health and social care professionals in providing person centered end of life care

3. Case 1: Mary Walker Mary Walker 45 year old female Been referred to an ENT consultant for recurrent tonsillitis (3 in the past 12 months) The primary treatment offered to Mary is a tonsillectomy Mary refuses the surgery.

4. Case 1: Mary Walker What are the requirements for capacity? What other factors would you want to know about Mary? Is this refusal valid?

5. Case 2: Sarah Milligan Sarah Milligan 26 year old Jehovah’s Witness Admitted for emergency twin delivery caesarean section at 27 weeks gestation following placental abruption and haemorrhage She requires a life saving blood transfusion – which she refuses

6. Case 2: Sarah Milligan Is this refusal valid? In which three circumstances can a doctor override a capacitous refusal of treatment? If the doctor had proceeded to give the blood transfusion against the patients refusal what could he have been charged with?

7. Case 3: Leonard Pace Leonard Pace, 66 year old male Has come to the GP to discuss an Advance Decision to Refuse Treatment (ADRT) after being diagnosed with Motor Neurone Disease He has decided that when his disease progresses to the point where he cannot breathe on his own, he does not wish to be ventilated in order to sustain life.

8. Case 3: Leonard Pace What is the purpose of an ADRT? Describe the legal framework for ADRTs How do validity and applicability apply in situations involving ADRTs?

9. Case 3: Leonard Pace What limits are there on advance decisions? What is the implication of an ADRT for HCPs? What if the HCP has a conscientious objection to the ADRT? What happens if the patient was to make a specific advanced request for treatment?

10. Case 4: Ronald Frume Ronald Frume, 92 year old male Admitted to ITU with severe pneumonia and sepsis He has advanced dementia His daughter has Lasting Power of Attorney She makes the decision to withdraw active treatment and allow him to die

11. Case 4: Ronald Frume What is Lasting Power of Attorney? What are the legal requirements for LPA? What can the LPA make decisions about and what specifications must be made about decisions surrounding life sustaining treatment?

12. Case 5: Berry Marie Berry Marie, 81 year old female Palliative care for breast cancer with metastases to liver and brain Has a DNAR Collapses in the outpatient department following an appointment with her oncologist. She is not breathing and her heart has stopped beating.

13. Case 5: Berry Marie When can a DNACPR order be placed? Are doctors always required to provide CPR? If not, what needs to guide the decision?