The scene

A GP member contacted the MDU advice line about a female patient in a nursing home, who had pneumonia and was at high risk of developing life-threatening sepsis.

The GP had been told there was an advance decision in place in which the patient had stated that she did not want to be treated with antibiotics, but was unclear whether the document would count as valid refusal of potentially life-saving treatment.

The GP had not been given the advance decision document by the patient, and so obtained a copy from the relative. The family was clear that the patient would not have wanted treatment with antibiotics, even if the consequences of that decision could be death, but the GP was not absolutely sure of the status of the document and called the MDU.

MDU advice

An advance decision can take many forms and does not always have to be in writing. However, if the decision requires refusal of life-sustaining treatment, the advance decision must be in writing and signed and witnessed. It also should clearly state which treatment the patient wants to refuse, and that the decision applies even if the patient's life is at risk.

An advance decision needs to have been made when the patient has capacity, but it only becomes valid when the patient no longer has capacity. As capacity is time and decision specific, it is important it is assessed at the point at which an advance decision is being acted on.

In this instance, and especially because the GP had not been given the advance decision document by the patient directly, the adviser asked the member to send in an anonymised copy of the advance decision for review and further advice. It emerged that the document had been signed and witnessed appropriately two years before, and stated that the patient wished to refuse antibiotics in any circumstance, even if their life was at risk.

The member was advised to assess and document in the records the patient's current capacity to refuse treatment. If she did not have capacity, the adviser recommended the GP to ask if there was evidence of the advance decision being revised or revoked by the patient in the two years since it had been signed. Provided that there was nothing to suggest that she might have changed her mind, the advance decision was valid and applicable to the current circumstances.

The outcome

The GP was satisfied that the patient did not currently have capacity and there was nothing to suggest that she had altered her views after making the decision while she still had capacity. The GP was reassured that in not treating the patient with antibiotics, he was acting both lawfully and in accordance with the patient's wishes. He put in place the appropriate palliative care to keep the patient comfortable.

Summary

Advance decisions can come in many forms, but those related to a refusal of life-sustaining treatment are only valid when made in writing. Before acting on an advanced decision, it is important to carefully review its validity and assess the patient's current capacity to refuse treatment.

Advance decision to refuse antibiotic treatment

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