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The role of advance statements
Advance statements regarding treatment decisions are recognised in many countries and can help professionals be guided to appropriate decision making when patients lack capacity.
In relation to sedation at the end of life there may difficulties. For example it may be very difficult to discuss these issues in advance. To raise sedation at an earlier stage may result in misinterpretation and only impair later decision-making. It is not clear whether people can fully comprehend the issues around sedation or know what their experience is going to be. It would be misleading to just make advance planning regarding sedation, all possible decisions after the patient loses capacity would need to be included.
The BMA (2004) questions whether people should be able to decline basic care, defined as interventions with the sole purpose of providing comfort. It could be argued that sedation would come into this category.
However, despite these criticisms of specific advance statements, there would seem to be a good argument for more general wishes or values to be documented. The key considerations for patients to reflect on could be
- Their need for comfort and freedom from distress
- Their wish to avoid any shortening of life
- Their wish to maintain consciousness and clarity of thinking for as long as possible
- The relevance to them of the views and needs of those close and the effect on them of watching any distress
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