Whether speaking to patients or their family members, discussions around end-of-life care can prove difficult for any doctor. GPs are often the first point of contact at this sensitive time and may find themselves dealing with a variety of issues arising from a terminal diagnosis, so it is important to consider possible scenarios and implications of their role.
When the diagnosis is confirmed
Coming to terms with a terminal diagnosis and its repercussions can be particularly traumatic for patients and their families. Good communication at an early stage is essential. However, end-of-life care is often delivered by multidisciplinary teams which can pose some challenges.
It can be helpful for a GP to make contact with patients when the initial diagnosis is made as they are uniquely placed to coordinate care from the beginning and may have knowledge of their medical history and good rapport with them.
GPs should work with colleagues and specialists in ways that best serve their patients’ needs and ensure that information is communicated effectively between professionals, as well as to the patient. This may involve liaising with community nurses and palliative care teams as well as signposting sources of support from organisations such as Macmillan and Marie Curie.
GPs can also facilitate conversations around any concerns the patient may have and can help with discussing coping mechanisms, support and counselling.
Discussing the patient’s medical care plan
The GMC’s guidance on treatment and care towards the end of life indicates that patients are likely to want the opportunity to decide what arrangements should be made for the final stages of their illnesses.
It also recommends that if a patient has a condition that might lead to a loss of capacity, their doctor should encourage them to think about what they might want should this happen. In addition, in a recent landmark ruling on resuscitation, it was found that doctors have a duty to consult their patients where practicable about their wishes and feelings on this matter, and that this is better undertaken at the earliest stages of the clinical relationship.
Formalising the patient’s wishes
Patients nearing the end of their life may wish to formalise their wishes in the form of an Advance Decision or a Lasting Power of Attorney (LPA).
Although advance decisions can be can be oral or written, the Mental Capacity Act requires that advance decisions refusing life sustaining treatment need to be in writing, witnessed and signed and state that it applies even when life is at risk.
An LPA allows people to nominate a person to make decisions on their behalf should they lose capacity, can cover property and financial affairs as well as health and welfare, and must be registered with the Office of the Public Guardian.
At this time, patients may also choose to draw up or amend their will, and in doing so, their GP can be asked to carry out an assessment for testamentary capacity. It is important to consider that the patient may be in a vulnerable state.
If a GP is making this assessment they should follow the test set out in Banks v Goodfellow which indicates that the patient must:
Understand the nature of making a will and its effects and the extent of the property which he or she is disposing,?
- Be able to comprehend and appreciate the claims to the estate (those who might benefit and be excluded from the will)?
- Be free of any disorder of the mind that influences him or her to make a decision in the will that would not otherwise have been made. ?
- Solicitors may ask the GP to provide confirmation at the time of their assessment or justify their decision if a dispute later arises over the will.
Dealing with family members and maintaining confidentiality
It is likely that family members of patients with terminal illnesses will request information about the patient and try to be involved in their care. However, GMC guidance on confidentiality states that GPs should establish with the patient what information they want them to share, who with and in what circumstances.
This guidance goes on to state that the duty of confidentiality continues after a patient has died and that if the patient had asked for information to remain confidential, their wishes should usually be respected.
However, GPs are able to use their discretion and in situations where they have no reason to believe that the patient would have objected to such a disclosure, they are able to share relevant information to a partner, close relative or friend.
In summary, there can be several aspects to providing end-of-life care which have medicolegal implications. Ensuring that these difficult conversations are conducted as sensitively and supportively as possible for the patient is paramount. Good communication with the patient and other members of the multi-disciplinary team, as well as an understanding of relevant professional and legal obligations, can assist with this.
- Dr Bobby Nicholas is medicolegal adviser at Medical Protection