Forum.
Table
Factors affecting capacity towards the end of life
- Spread of disease to brain or meninges
- Drug side effects
- Anxiety
- Depression
- Emotional adjustment to condition
- Fears of increase pressure on family and friends
Health professionals have a responsibility to take every step to enhance capacity. This may include the following
- Adjusting the environment to ensure most effective communication and patient safety
- Symptom management
- Adjusting medication with euphoric or sedative properties
- Treating depression or anxiety
- Addressing communication issues
This raises questions in dealing with patients who may benefit or are benefiting from sedation. Presuming the above steps have been covered; it would be difficult to justify withdrawing sedation or other medication in order to try to achieve increased capacity for consent.
A patient lacking capacity offers a challenge to a health care team as to how to approach decision-making. In the UK the legal responsibility lies with the doctor in charge of the patient’s care. The British Medical Association suggests the following issues are considered when making decisions for patients who lack capacity.
- Liberty. The least restrictive of all options should be employed, with appropriate justification, and enabling maximum enjoyment of life. This would mean using the lowest dose of sedation possible and excluding other treatable conditions.
- Autonomy should be promoted as far as possible.
- Dignity should be preserved as far as possible. This would include social and cultural views as well as respect and courtesy. It is debatable as to whether sedation promotes or impairs dignity.
- Patient views should be taken into account as far as possible
- Privacy. No interventions should be undertaken on sedated patients unless there are good reasons why they are needed.
- Health needs need to be met as far as resources will allow. This does put a responsibility on professionals to ensure appropriate interventions are still taken according to need even when patients may not be aware.
- Free from unfair discrimination
- Having views of those close to them taken into account although not asking them to make the decision. Consider the role of proxy decision makers.
- Consider a second opinion
- Involve the team in any decisions
- Consider any anticipatory statements made by the patient
Generally refusing an advised course of action will have more serious consequences for a patient as health care teams will want to advance their best interests. Refusals are therefore considered in more detail, though the same level of capacity is required to both accept and decline treatment.
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