End of life care and DNAR Rachel Podolak, Head of Welsh Affairs

Who we are and what we do Our role is to protect, promote and maintain the health and safety of the public. We maintain the register of doctors and set the standard for entry to the register We set and promote the principles and values of good medical practice from medical school to retirement. We take action to protect patients. Manchester Manchester.

Hitting the headlines

End of life care - key principles  The presumption in favour of prolonging life - not an absolute obligation  Life-prolonging treatment can be withdrawn or not started – if refused; or if it is not of overall benefit to a patient who lacks capacity to decide  Plan ahead as much as possible with the patient, healthcare team, carers and other services  Provide appropriate palliative care e.g. pain relief  Respect patients’ views and wishes. Treat patients and their carers with sensitivity, dignity, and fairness

Issues covered in the guidance  Equalities and human rights 7-13  Advance care planning (incl. palliative care)  Advance requests for/refusals of treatment  Clinically assisted (artificial) nutrition and hydration (C/ANH)  Cardiopulmonary resuscitation (CPR)

Advance requests Advance requests for treatment:  Not legally binding – evidence of a patient’s wishes  Will carry weight in future decisions about the balance of benefits, burdens and risks of treatment.  If the benefits, burdens & risks of a treatment are finely balanced; the patient’s previous request to have it will usually be the deciding factor.

Advance refusals Advance refusals of treatment:  Must be ‘valid and applicable’ to be legally binding  If not – then treat as evidence of a patient’s wishes

Do Not Attempt CPR decisions  The decision making principles that apply to other treatments also apply to CPR when doctors are deciding if it should be attempted at a future date. We ask doctors to be clear about:  when to talk about a DNACPR order with patients and/or their family and carers  what to explain – public myths; patients’ fears  whether they are ‘consulting’ or ‘informing’  the different roles of the doctor/team, patient and family, in making the decision

Decision making

And finally…. Questions you may wish to consider:  Was it good clinical practice (up to date, evidence based)?  Were GMC decision-making principles applied?  Were the issues considered carefully; and was advice sought?  Did the Dr make a ‘reasonable’ decision in the circumstances?