1. Critical Care at the End of Life The UK Experience
Dr Peter O. Beaumont, MD, MSc, FRCA, FFICM, DIMC
Consultant in Anaesthetics and Intensive Care Medicine
Senior Lecturer in Paramedic Practice
Lead for Patient Transfers, SLACCN
(Occasional Prehospital Doctor)

3. Overarching policies and principles
Mental Capacity Act 2005
GMC Good Medical Practice 2017
Guidelines for the Provision of Intensive Care services 2015
NICE: Care of dying adults in the last days of Life 2015
BMA: Policy on physician-assisted dying. 2017

4. Assessing capacity 4 Criteria
Understand information given to them about a particular decision
Retain that information long enough to be able to make the decision
Weigh up the information available to make the decision
Communicate their decision.
Assessment indexed to the decision being made

5. The key principles however are:
Every adult is assumed to have capacity until determined otherwise
No one can make a decision for another person unless they lack capacity to make the decisions themselves
The only persons/bodies who can make significant medical decisions for others who lack capacity are:
Lasting powers of attorney (LPA)
The judiciary
Doctors in charge of a patient’s care (Usually Consultant level in the NHS)

10. Ceilings of Therapy
Colloquial term for Withholding care rather than withdrawal.
We will use all treatment that is necessary, “up to a ceiling of” X.
Frequently used in the English NHS
Often formalised on documents such as:
PTEP: Personalised Treatment Escalation Plan
DNACPR: Do Not Attempt Cardiopulmonary Resuscitation

11. Ceilings of Therapy Examples:
For Non-invasive ventilation but not for intubation
Inotropes to counter sedation, but nothing more
Not to go back on mandatory ventilation once weaned
For fluid management of AKI, but not for renal replacement therapy

12. A typical UK family discussion
What do you understand has happened and what are we doing for the patient
Explain the situation from our point of view including potential outcomes and what they might look like in both short and long term
Enquire if the patient had ever expressed any preferences or held formal advanced directives

13. A typical UK family discussion
Enquire what the family believe the patient would want, not what they want for them, if the patient could tell us directly
Explain that in absence of an LPA (etc), that the duty/burden to make decisions rests with me/us, and not them. They do not need to feel as though they made the decision
If the NoK disagree after a 2nd opinion (we often discuss this amongst ourselves beforehand), then we will support their application to the court for a ruling. I have never seen this done in adult practice.

14. Withdrawal of Care - practicalities
Immediately, on decision to shift the focus of care to palliation:
Record the decision and rational in patient notes & complete DNAR form
Stop all further tests (except in case of brainstem death testing)
Stop all non-essential drugs & prescribe palliative medicines (doctrine double effect)
Referral to palliative care team for nearly all cases
Offer pastoral support

15. Withdrawal of Care - practicalities
Once family have assembled and said respective words
Mute all alarms. Monitor observations remotely if possible
Stop renal replacement therapy
Stop all inotropes and vasopressors
Move ventilator to room air, CPAP 5 and stop pressure support.

16. Withdrawal of Care - practicalities
If oxygen and ventilator requirements are minimal
Consider Swedish nose to ETT and remove ventilator
Consider extubation and move to simple airway adjuncts (OP/NPA)
If after the above is performed death is not imminent, consider transfer to side room on ward, otherwise remain in critical care

17. Questions and Thank You…
Dr Peter O. Beaumont, MD, MSc, FRCA, FFICM, DIMC
Consultant in Anaesthetics and Intensive Care Medicine
Senior Lecturer in Paramedic Practice
Lead for Patient Transfers, SLACCN