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British group says patients can refuse treatment

By Richard Woodman

LONDON, Apr 30 (Reuters Health www.reutershealth.com) - Patients have the right to refuse medical treatment even if this results in their death, according to draft new guidance issued by the body that regulates doctors working in Britain.

The General Medical Council (GMC) said it believed complex ethical issues should be clarified in the light of the high profile case of "Miss B", who fulfilled her wish to die in her sleep after winning the right to have her life support machine switched off. Miss B, who cannot be named for legal reasons, had been the first person in Britain in full control of their mental faculties to have asked successfully for doctors to switch off her life support system.

"In this modern day and age, the idea that doctor knows best is something of the past," said David Hatch, head of the GMC group working on the guidelines, which are likely to be adopted by the GMC on May 21.

"I think that the overriding principle, which was confirmed in the 'Miss B' case, is that one must respect the wishes of the patient and make sure they are fully informed about all the options and free to make their own decisions," Hatch told BBC radio.

On Monday at the European Court of Human Rights, terminally ill motor neurone sufferer Diane Pretty lost the final round of her legal fight to die with her husband's help.

At an emotional news conference in London on Monday, Pretty, who speaks with the help of an electronic device, said: "The law has taken all my rights away."

Hatch said that the GMC, which has been drawing up the guidelines for 18 months, worked from the position that mercy killing or euthanasia is contrary not only to the law in Britain but to the ethics of medicine. "But prolonging life unnecessarily, especially if it is producing distress and discomfort, is not good medicine," he added.

The GMC guidance states that while doctors must show respect for human life they should not strive to prolong the dying process without regards for the patient's wishes.

"Adult competent patients have the right to decide how much weight to attach to the benefits, burdens, risks and the overall acceptability of any treatment. They have the right to refuse treatment even where refusal may result in harm to themselves or in their own death, and doctors are legally bound to respect their decision."

If a patient lacks the capacity to decide, the guidance says that the healthcare team and those close to the patient should try to agree what is in the patient's best interests. If they cannot agree, legal advice should be sought on whether to seek a court ruling.

"Although it may be emotionally more difficult for the healthcare team, and those close to the patient, to withdraw a treatment from a patient rather than to decide not to provide a treatment in the first place, this should not be used as a reason for failing to initiate a treatment which may be of some benefit to the patient," the guidance adds.

"Where it has been decided that a treatment is not in the best interests of the patient, there is no ethical or legal obligation to provide it and therefore no need to make a distinction between not starting the treatment and withdrawing it."

The guidance says that doctors who have a conscientious objection to a decision to withhold or withdraw life-prolonging treatment may withdraw from the care of that patient.

The report admits that decisions involving artificial nutrition and hydration may be difficult and contentious.

"For some patients not taking nutrition or hydration may be part of the natural dying process. (But) problems in making assessments can arise because some patients may under-report their symptoms, while perceptions may differ between doctors, members of the healthcare team and those close to a patient, about the presence or severity of symptoms such as pain.

"In view of these considerations, it is essential that doctors ensure that those involved in the decision making are provided with clear and up-to-date information, about what is known of the benefits, burdens and risks of providing nutrition and hydration through artificial means, and information about the basis on which the particular patient's needs have been assessed."

The guidance adds that cardiopulmonary resuscitation (CPR) has a low success rate, especially for patients with serious conditions who are in poor general health. "If used inappropriately, it may do more harm than good by prolonging the dying process and the pain or suffering of a seriously ill patient, in a manner which could be seen as degrading and undignified.

"For example, if a patient is at the end-stage of an incurable illness and death is imminent, attempts to resuscitate them are likely to be futile and not in the patient's best interests."

The guidance says doctors must respect patients' decisions to refuse CPR. However, if patients say they want CPR, doctors should usually comply with their wishes, even though they are under no obligation to provide treatments they consider futile.

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