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Views And Reviews Acute Perspective

David Oliver: End of life care in hospital is everyone’s business

BMJ 2016; 354 doi: (Published 14 July 2016) Cite this as: BMJ 2016;354:i3888

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Yes: End of life care everywhere is everyone’s business

I am pleased to see that Dr Oliver writes in his article 'These included patients or loved ones discussing their own concerns and choices'. Because a lot of end-of-life guidance written by clinicians, seems to avoid describing patients expressing their clear choices - which I think should be more clearly worded as decisions or instructions - and instead typically mentions 'the patient's wishes and preferences'. The word 'wishes' is not appropriate when describing a decision: I can decide to take an umbrella with me in case it rains, and I can wish it doesn't rain'. And 'preferences' is better used in connection with things which are less clear than decisions: 'I never eat oranges, and I often have a preference for pears over apples'.

The thing that really bothers me about this, is the contemporary promotion of 'advance statements' from patients, instead of the promotion of the much more helpful Advance Decisions (I discuss this in ref 1). The point being that if the patient loses mental capacity, and there is a decision to be made, a clear decision previously expressed by the patient should be followed, but 'patient preferences' are merely things which a best-interests decision-maker would need to be considering: and best-interests decision-making is a fraught and complex process, best avoided if at all possible.

There might be something going on with the way people use words, which further clouds this issue. I recently asked on a Facebook page 'Are – and I'm not being sexist, nor am I trying to start a discussion of 'why this might be true, if it is true' – women, when describing their definite refusal of something, more likely than men to say 'I wish to' or 'I would prefer' instead of 'I've decided to' ?'.

Fundamentally (ref 2) you need to get the words right, or else you risk confusing informed consent with best-interests decision-making.

Ref 1

Ref 2

Competing interests: No competing interests

14 July 2016
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN