Statements requesting specific treatment options should normally be respected,
but cannot override professional judgements, as in law no-one can dictate how
health care teams should proceed. By contrast, the cases ofRe T adult: refusal of
treatment)41992),Airedale NHS Trustv.Bland41993) andRe C adult: refusal of
treatment)41994) confirmed that statements which take the form of an advance
refusal of treatment have full effect in law, provided that they are clearly drafted,
with full understanding of their implications, and cover the circumstances which
subsequently occur. It follows that the flouting of an advance refusal allows a
patient to claim compensation in respect of the unauthorised physical contact.
The case ofRe T,mentioned in the last paragraph, illustrates some of the pro-
blems linked with advance refusals. T was a young pregnant woman admitted to
hospital after a road traffic accident. A decision was made to deliver her baby by
caesarean section, and the issue of administering blood was raised in this context.
T, whose mother was a fervent Jehovah's Witness, asked whether there was a
substitute treatment and was told that there was. She then signed a form of refusal
of consent to blood transfusions. The form was not read out or explained to her,
nor was she advised of the risk to her own health and life which her refusal
entailed. Following the caesarean section 4the baby was stillborn), T's condition
deteriorated and she was transferred to intensive care. After she became uncon-
scious, her father and boyfriend sought a declaration from the court that it would
be lawful for the hospital to administer blood, despite T's prior refusal.
The Court of Appeal emphatically endorsed the right of adults to reject medical
advice and treatment, if their decision is reached while they have the capacity to
make it. The judges then explored T's capacity at the point at which she refused the
transfusion. They found that her capacity had been undermined by the influence
of her mother, by the pain and confusion T was in and by the failure to fully advise
her of the potentially serious consequences of her decision. In the light of this
finding, the proposed blood transfusion was declared lawful.
The decision shows that advance refusals must be approached with some cau-
tion, and with attention to the circumstances in which they were made, if these are
known. Additional guidance on their implementation can be found in the 1995
Code of Practice,Advance Statements about Medical Treatment[19], prepared by the
BMA for health professionals. The Code recommends that:
`all staff involved. .. should have an opportunity of presenting their views. From
apatient's viewpoint, nurses are often the most accessible professionals.. ..
nurses may have had closer contact than others with the patient, and those close
to the patient. Nurses are often adept in translating technical medical language
and discussing practical outcomes of treatment and care. They may gain
particular insight into whether patients were consistent and coherent in their
views.'Although for several years the Law Commission has recommended that there
should be legislation in this sphere,Making Decisionsconfirms that the Govern-
ment prefers the law to develop case by case [20]. Nurses must accordingly strive to
monitor new court decisions which are relevant to advance statements.
At European Convention level, advance refusals are only weakly recognised [21].
The European Convention on Human Rights contains no direct reference to them.
The Critically Ill Patient 205