Practice dilemma - Dementia patient's care plan

The Dilemma - You are called to a nursing home to see an elderly man with a chest infection. In his care plan, it states he would like to be cared for at the home and that he would not like to be transferred to a hospital should he fall ill. After reviewing him using the CRB65 assessment tool, you note he has severe pneumonia and is at risk of death. His daughter is present and comments on how confused and breathless he is. You explain that he needs intravenous antibiotics and oxygen in hospital but unfortunately his care plan states that you have to treat him in the nursing home, which does not have the facilities for oxygen or intravenous drugs. She objects to this and, despite the care plan, insists he is transferred to hospital. What should you do?

GPs should always remember that their primary duty is to their patient (Photograph: SPL)

GP's view - Dr Dan Bunstone is a GP principal in Cheshire
The three key issues for consideration are the clinical need to treat the patient, the patient's wishes and the current wishes of the family.

If the patient has made a previous advanced directive while fully competent to do so, then this would be my primary consideration.

I would like to know how and when the directive was made and if the patient had capacity to make the decision at that time.

Did they really mean they wanted to be left to deteriorate with a potentially curable illness, or did they perceive this directive to apply for something more serious such as terminal stroke or cancer care?

If we believe the directive was made with full understanding and capacity, then the patient's wishes need to be observed.

The daughter will be angry, and will instinctively want to do all that she can to keep her father alive. I would invite the daughter to discuss the situation, and where possible to involve other family members. My aim would be to reach a common decision with which everyone is happy.

If there continues to be conflict and no resolution achieved, we could apply to the court for a decision to be made.

This is a tricky and not uncommon problem we encounter.

It highlights the problems of advanced directives and the importance of next of kin being involved.

A medico-legal opinion - Dr Pallavi Bradshaw is a medico-legal adviser for Medical Protection Society
This scenario is not uncommon and many GPs will find themselves in similar situations. It is important to remember that your primary duty is to your patient.

There are many complex legal and ethical issues related to autonomy, capacity and consent. Case law, statute (Mental Capacity Act 2005 and Adults with Incapacity Act 2000) and GMC guidance are increasingly emphasising a patient's right to determine their treatment.

The patient appears to lack capacity but you should confirm this formally and document your findings. The care plan states the patient's wishes, but it is unclear whether this life-threatening situation was ever contemplated. Further, you should bear in mind how long ago the care plan was made and whether there is any indication that his views may have changed or that he lacked capacity at the time of those discussions.

As you are unsure about these aspects and in the absence of a lasting power of attorney or welfare attorney you should act in the patient's best interests.

You should take into account the clinical aspects, the patient's known views, values and beliefs and indeed the daughter's concerns.

If you are uncertain about the clinical assessment you should request a second opinion and ensure you keep detailed records of the decisions taken.

A patient's view - Danny Daniels is an expert patient
Personal care plans are packages of care that are personal to the patient.

It involves working with professionals, who understand their needs, to agree goals, the services chosen, and how and where to access them.

There appears to be three main questions that arise:

1. Is the care plan valid and was it arrived at using a designated code of practice and co-signed and witnessed?

2. During the process of completing the plan, were the implications of possible refusal of hospital treatment in the future explored in depth?

3. Does the patient's present capacity to understand override his previously expressed wishes?

The GMC guidelines are comprehensive and give valuable indicators on what actions the clinician should do in such circumstances. Their online guidance sections 75-79 are particularly helpful.

The Mental Capacity Act 2005 section 4 is also an applicable reference, particularly in terms of the patient's capacity to understand in his present condition.

On one hand we have the daughter who would like to see her father's health improve. And, on the other, we have the clinician following the wishes which were previously expressed when the patient was cognisant.

This is a difficult situation for the GP to be in.

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