Advance Decisions should not be 'mingled with' advance statements
The ‘mylivingwill’ website pointed at by Isky Gordon (this series of rapid responses, 03 March) tells readers on its homepage ‘My Living Will consists of both an Advance Decision to refuse treatment and an Advance Statement of your preferences and wishes’.
This ‘mingling’ of an Advance Decision, which is in simple terms a decision already made and recorded by the patient, and which should then be followed by everyone else, with an ‘advance statement’, is entirely unhelpful. The existence of a written ‘advance statement’ after the patient has lost capacity, is nothing like as helpful: these ‘advance statements’ are merely things which must be considered during Mental Capacity Act section 4 ‘best-interests decision-making’, and compared to following an Advance Decision, best-interests decision-making is hugely more complex. And, despite a contemporary ‘fashion’ for the creation during clinical contact with mentally-capable patients of ‘written advance statements’, that idea is not really present in the MCA. The MCA tells anybody faced with making a best-interests decision to consider ‘any relevant written statement made by him when he had capacity’. So, if you first come into contact with a patient only after the patient lacks capacity, you might find something previously written which qualifies as ‘a relevant written statement dating from when the patient had capacity’: that is not a justification to over-promote the deliberate creation of ‘advance statements’ during situations of ongoing care.
The complexity, is inside ‘the considering’: clinicians and care staff should be stressing the option that patients can create advance decisions and thereby ‘reclaim the decision-making’, instead of encouraging patients to record ‘preferences’ [unless we are talking in terms of ‘acceptance of treatment’, which is outside the scope of an advance decision].
If you want to understand ‘the patient’s ‘views on life’’ – which is at the core of the best-interests decision-making process – the best approach if the patient has not explained that to you face-to-face, is to ask the people who do ‘know the patient’ (the patient’s close family and friends). These ‘advance statements’ are very close to ‘irrational’ as I have pointed out (ref 1).
As Dr Oliver writes ‘…to do the right thing for residents rather than feel obliged to use acute admission as the default option’: in principle ‘the right thing’ would be to [assuming the patient cannot make the decision at the time] make a ‘good’ MCA best-interests decision, but care home staff probably lack the confidence to make and defend a ‘the patient should stay here’ decision. And written ‘advance statements’ are not the answer – as Dr Oliver states, better training, etc, is needed, both for the MCA and for end-of-life in general.
Rapid Response:
Advance Decisions should not be 'mingled with' advance statements
The ‘mylivingwill’ website pointed at by Isky Gordon (this series of rapid responses, 03 March) tells readers on its homepage ‘My Living Will consists of both an Advance Decision to refuse treatment and an Advance Statement of your preferences and wishes’.
This ‘mingling’ of an Advance Decision, which is in simple terms a decision already made and recorded by the patient, and which should then be followed by everyone else, with an ‘advance statement’, is entirely unhelpful. The existence of a written ‘advance statement’ after the patient has lost capacity, is nothing like as helpful: these ‘advance statements’ are merely things which must be considered during Mental Capacity Act section 4 ‘best-interests decision-making’, and compared to following an Advance Decision, best-interests decision-making is hugely more complex. And, despite a contemporary ‘fashion’ for the creation during clinical contact with mentally-capable patients of ‘written advance statements’, that idea is not really present in the MCA. The MCA tells anybody faced with making a best-interests decision to consider ‘any relevant written statement made by him when he had capacity’. So, if you first come into contact with a patient only after the patient lacks capacity, you might find something previously written which qualifies as ‘a relevant written statement dating from when the patient had capacity’: that is not a justification to over-promote the deliberate creation of ‘advance statements’ during situations of ongoing care.
The complexity, is inside ‘the considering’: clinicians and care staff should be stressing the option that patients can create advance decisions and thereby ‘reclaim the decision-making’, instead of encouraging patients to record ‘preferences’ [unless we are talking in terms of ‘acceptance of treatment’, which is outside the scope of an advance decision].
If you want to understand ‘the patient’s ‘views on life’’ – which is at the core of the best-interests decision-making process – the best approach if the patient has not explained that to you face-to-face, is to ask the people who do ‘know the patient’ (the patient’s close family and friends). These ‘advance statements’ are very close to ‘irrational’ as I have pointed out (ref 1).
As Dr Oliver writes ‘…to do the right thing for residents rather than feel obliged to use acute admission as the default option’: in principle ‘the right thing’ would be to [assuming the patient cannot make the decision at the time] make a ‘good’ MCA best-interests decision, but care home staff probably lack the confidence to make and defend a ‘the patient should stay here’ decision. And written ‘advance statements’ are not the answer – as Dr Oliver states, better training, etc, is needed, both for the MCA and for end-of-life in general.
Mike Stone mhsatstokelib@yahoo.co.uk
Ref 1 http://www.bmj.com/content/351/bmj.h6631/rr-0
Competing interests: No competing interests