Intended for healthcare professionals

Letters

Advance directives

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7262.705/a (Published 16 September 2000) Cite this as: BMJ 2000;321:705

Three questions should be asked

  1. Roger Hole, retired urologist
  1. Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
  2. Doctors for Assisted Dying, Suite 64, 2 Old Brompton Road, London SW7 3DQ
  3. Medical Ethics Committee, BMA, London WC1H 9JP
  4. Royal Free Hospital, London NW3 2QG
  5. St Damian's Surgery, Melksham, Wiltshire SN12 6JN
  6. Littleton Panell Surgery, Nr Devizes, Wiltshire SN10 4EX
  7. St Damian's Surgery, Melksham, Wiltshire SN12 6JN

    EDITOR—The paper by Diggory and Judd1 reporting the response to their questionnaire survey shows that there is an encouraging awareness of advance directives among the responding NHS trusts but very little evidence that trusts make any routine provision for recording the existence and whereabouts of an advance directive, prepared when the patient was both calm and competent.1

    The time to gather this information is on admission when name, address, date of birth, religion, and preferred name, etc are being recorded. Three simple questions added to the admission form would go a long way to alerting hospital staff to a (legally binding) directive that might otherwise be overlooked:

    (1) Do you have an advance directive (living will)? yes/no

    (2) Where is it kept? With general practitioner? yes/no

    At home? yes/no

    (3) If patient was admitted unconscious, has an advance directive card been looked for and found in patient's belongings? yes/no

    Asking these questions on admission rather than later might give the many patients who are currently unaware of advance directives an opportunity for a calm discussion with hospital staff. To raise the subject later—for example, when they are about to sign a consent form for treatment—would create unnecessary alarm and even confusion with a last will and testament.

    Footnotes

    • Mr Hole is a member of the Voluntary Euthanasia Society and Doctors for Assisted Dying.

    References

    1. 1.

    Maybe national guidelines are needed

    1. Michael Irwin, chairman
    1. Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
    2. Doctors for Assisted Dying, Suite 64, 2 Old Brompton Road, London SW7 3DQ
    3. Medical Ethics Committee, BMA, London WC1H 9JP
    4. Royal Free Hospital, London NW3 2QG
    5. St Damian's Surgery, Melksham, Wiltshire SN12 6JN
    6. Littleton Panell Surgery, Nr Devizes, Wiltshire SN10 4EX
    7. St Damian's Surgery, Melksham, Wiltshire SN12 6JN

      EDITOR—Perhaps the most interesting result of the survey by Diggory and Judd on advance directives was that three quarters of the NHS trusts responding to their questionnaire were in favour of national guidelines, which suggests that more trusts would consider addressing the issue if national guidelines were available.1

      One factor that might influence the NHS leadership to take action on national guidelines would be the expected economic benefits resulting from much greater use of advance directives. Recently, I saw a study conducted by the department of family medicine at Jefferson Medical College in Philadelphia, which showed that when the records of 474 Medicare patients who had died in hospital (in 1990, 1991, and 1992) were reviewed it was discovered that the mean inpatient charges for the 342 patients without documentation of a discussion of advance directives was more than three times that of the 132 patients with such documentation ($95 305 v $30 478).2

      If a mentally competent terminally ill adult wishes to complete an advance directive (possibly to hasten his or her inevitable death with the aid of a medical team), why not encourage this? The patient gets what he or she wants, and society saves money that would otherwise be spent on expensive and, most important, unwanted end of life care.

      References

      1. 1.
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      Legal issues need clarification

      1. Michael Wilks, chairman (gromano-critchley{at}bma.org.uk)
      1. Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
      2. Doctors for Assisted Dying, Suite 64, 2 Old Brompton Road, London SW7 3DQ
      3. Medical Ethics Committee, BMA, London WC1H 9JP
      4. Royal Free Hospital, London NW3 2QG
      5. St Damian's Surgery, Melksham, Wiltshire SN12 6JN
      6. Littleton Panell Surgery, Nr Devizes, Wiltshire SN10 4EX
      7. St Damian's Surgery, Melksham, Wiltshire SN12 6JN

        EDITOR—Diggory and Judd highlight inconsistencies in understanding of the legal issues around advance directives and suggest that national guidelines would encourage trusts to develop local policies to improve understanding and compliance with the law.1 Enquiries to the BMA from doctors and lawyers show similar confusion about the legally binding nature of advance directives.

        The BMA welcomes the government's recent statement of the legal position that, as a general point of law and medical practice, all adults have the right to consent to or refuse medical treatment, and advance statements are a means for patients to exercise that right by anticipating a time when they may lose the capacity to make or communicate a decision.2 The government is satisfied that the guidance contained in case law, together with the BMA's code of practice,3 is sufficient to provide clarity and flexibility without the need to introduce legislation governing advance statements at the current time. In response to this and Diggory and Judd, the BMA has placed its code of practice on the BMA website (http://www.bma.org.uk/) with a new introduction to update on legal developments.

        References

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        Advance directives are not legally binding

        1. Michael Jarmulowicz, consultant histopathologist (mjarmulowicz{at}compuserve.com)
        1. Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
        2. Doctors for Assisted Dying, Suite 64, 2 Old Brompton Road, London SW7 3DQ
        3. Medical Ethics Committee, BMA, London WC1H 9JP
        4. Royal Free Hospital, London NW3 2QG
        5. St Damian's Surgery, Melksham, Wiltshire SN12 6JN
        6. Littleton Panell Surgery, Nr Devizes, Wiltshire SN10 4EX
        7. St Damian's Surgery, Melksham, Wiltshire SN12 6JN

          EDITOR—Why does the BMJ consistently publish articles giving the mistaken impression that all advance directives are legally binding?1 The case that people assume upholds their legality is that of a patient at Broadmoor hospital who refused to have an amputation for gangrene. The judgment stated that if his mental state should change and he become mentally incompetent, then his refusal of an amputation, made while competent and after being given an explanation of the possible consequences of that refusal, remained valid. I agree with this judgment, which is very different from saying all advance directives are legally binding.

          The medical profession has moved from a paternalistic position of “doctor knows best” to one in which the patient gives informed consent. For consent to be valid the patient must understand both the expected benefits of the proposed treatment and the possible adverse consequences. If informed consent for treatment is right, then it is equally right, both morally and logically, that refusal of treatment should be equally informed. But informed refusal of treatment can be valid only if the specific facts pertaining to the current situation are available. It is likely that living wills will be made many years prior to mental incompetence, when details of the conditions specified—including possible treatments available—cannot be foreseen.

          In many scenarios a legally binding living will could bring about the distressing situation that the testator was trying to avoid. For example, a patient may state that surgery must not be performed if terminal cancer is present, but palliative surgery may be indicated in terminal bowel cancer, not to prolong life, but to relieve the distressing symptoms associated with unrelieved bowel obstruction. In such a case a legally binding “living will” will prohibit doctors from providing the most appropriate palliative care available.

          References

          1. 1.

          Good education prepares people for death

          1. Robert Hardie, general practitioner (RobClareHardie{at}aol.com),
          2. James Flood, general practitioner,
          3. Susan Frankland, general practitioner
          1. Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
          2. Doctors for Assisted Dying, Suite 64, 2 Old Brompton Road, London SW7 3DQ
          3. Medical Ethics Committee, BMA, London WC1H 9JP
          4. Royal Free Hospital, London NW3 2QG
          5. St Damian's Surgery, Melksham, Wiltshire SN12 6JN
          6. Littleton Panell Surgery, Nr Devizes, Wiltshire SN10 4EX
          7. St Damian's Surgery, Melksham, Wiltshire SN12 6JN

            EDITOR—As general practitioners of 50 years' collective experience and as professional lifelong BMA members (albeit disenfranchised because there is no local branch), we feel compelled to write after the publication of two articles on dying earlier this year. 1 2

            We find it sad that members of a noble profession are seemingly pushing so hard to organise death, on a “well if we can't beat it, lets join it” basis. The suggestion that doctors are duty bound to follow to the letter an advance refusal of treatment is wrong.1 According to Finnis, the law firmly and rightly holds that those who have undertaken to provide treatment or nourishment are not absolved from their duty by the patient's adamant refusal, if that refusal is either incompetent or unlawful.3 A refusal that is motivated by the intent to commit suicide is unlawful, even though suicide itself is not a criminal offence; that is why assistance, and agreements to assist, in suicide are criminal offences.3

            We applaud Smith's attempts at normalising dying and removing Western taboos, but we are horrified at the way he tries to stage manage the whole process.2 We cannot plan to deal with death in a tidy manner without being guilty of killing others or ourselves. Life and death march hand in hand every day, and a good education prepares young people for death, as well as for life (as stated at the headmasters' conference in 1994). Each of us should be ready for death at every moment of our lives.

            “Do not be afraid of those who kill the body but cannot kill the soul; fear Him rather who can destroy both the body and soul in hell.”4 The beginning of wisdom is fear of the Lord, but that fear ultimately is cast out by perfect love. In life and in death we are invited to join that perfect love on His terms, not ours.

            We have sincere respect for those who find this last paragraph unacceptable but plead with them not to let their personal views cause immeasurable harm to society. However well intentioned they may be there is the serious threat that human frailty, being what it is, will distort their vision and promote state coercion and individual corruption.

            References

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