treatment could be withheld from R at the point where his life became `so afflicted
as to be intolerable'. Proposed interventions would have to be assessed in the light
of the benefits they could confer on the patient.
Where there is doubt as to how to proceed, treatment can be initiated with a
view to assessing its effects on the patient. Although it may be emotionally easier to
withhold treatment than to withdraw it, such a policy has no legal justification. Of
course, if treatment is withdrawn, basic care should always be provided, and oral
nutrition and hydration should be offered.
New guidelines [25] issued by the British Medical Association recommend that
the decision to cease treatment should be taken by the clinician in overall charge of
the patient's care, in the light of the best available clinical evidence and the views of
the rest of the health care team. Withholding or withdrawing artificial nutrition or
hydration should additionally require authorisation by a senior clinician outside
the team. It should, however, not be necessary to go to court in each case.
10.4.6 Case study[26]
Declan, aged 88, suffered a massive stroke 15 days ago. He is completely paralysed
on one side of his body and almost completely on the other. His condition has
steadily deteriorated and he is now unable to chew or swallow food. He no longer
appears to recognise, or respond to, his only child, Siobhan, or to the nurses. The
medical team are unsure whether to commence artificial nutrition. Siobhan claims
that her father would not wish his life to be prolonged in this way.
As Declan cannot comprehend or process the factors involved, he has lost the
capacity to make his own decision about artificial nutrition. As his daughter has
alerted the health care team to what her father's wishes were likely to be, she
should be asked whether Declan prepared an advance refusal. If there is evidence
that a refusal was drawn up, attempts should be made to obtain the latter or some
record of it 4perhaps in the medical notes kept by Declan's GP). If such a refusal
was issued with understanding of its implications and deals with the situation
which has now arisen, it is binding on the health care team.
In the absence of an advance refusal, the health care team must consider whe-
ther the provision of artificial nutrition would benefit Declan. It can be withheld if
this serves Declan's best interests. Declan's prospects of recovery and the likely
quality of his life then, should be assessed. If the decision is to withhold treatment,
it should, in compliance with the 1999 BMA guidelines, be vetted by a neurologist
outside the team. A cautious team might seek a court declaration.
10.5 Conclusion
Legal problems commonly associated with the delivery of health care tend to
present themselves in acute form during the management of critical illness.
Assessing the patient's capacity to make treatment decisions and working out
where a patient's best interests lie become more difficult than usual. The need for
limits to the duty to maintain life, and for court intervention at key points of
208 Nursing Law and Ethics