Intended for healthcare professionals

Analysis Ethical debate

Are advance directives legally binding or simply the starting point for discussion on patients’ best interests?

BMJ 2009; 339 doi: (Published 26 November 2009) Cite this as: BMJ 2009;339:b4667
  1. Stephen Bonner, clinical director critical care1,
  2. Michael Tremlett, consultant anaesthetist1,
  3. Dominic Bell, consultant in anaesthesia and critical care2
  1. 1James Cook University Hospital, Middlesbrough TS4 3BW
  2. 2Leeds General Infirmary, Leeds LS1 3EX
  1. Correspondence to: S Bonner stephen.bonner{at}

    Following advance directives in emergencies throws up some complicated problems, as Stephen Bonner and colleagues found. We asked an emergency doctor (doi:10.1136/bmj.b4697), a medical defence adviser (doi:10.1136/bmj.b4693), and an ethicist (doi:10.1136/bmj.b4695) what they would do in the circumstances

    The ethical principle of respect for autonomy has progressively overtaken paternalism in the interface between medical profession and patients. For competent patients this translates into the concept of informed consent. In addition, the Mental Capacity Act 2005 enabled individuals to write an advance directive or appoint a lasting power of attorney to make their views on health care known should they lose capacity.1 However, these rights are limited to planned refusal of specific medical treatments, and even this is vulnerable to challenge if the directive is not sufficiently specific.

    The following case study explores the questions that arise with regard to an advance decision to refuse treatment in the context of a life threatening overdose.

    Case history

    A 62 year old woman, bed bound with severe arthritis and in constant pain despite strong opioid treatment, presented to the emergency department unconscious with an obstructed airway and absent gag reflex. A suicide note documented that she had taken an overdose up to 24 hours previously of chloral hydrate, diazepam, paracetamol-codeine combination, and alcohol. The note also clearly expressed the patient’s distress at her longstanding pain and severe restriction of function and independence. Her general practitioner had called for the ambulance with the support of her husband, who presented medical staff in the emergency department with an advance directive signed by the patient (see stating that she did not want life sustaining medical treatment. Her husband emphasised that although the family would ideally want her advance directive followed, they would support any actions and treatment taken by the healthcare team in …

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