Advance directives
An advance directive is a statement made by a competent adult in anticipation of a time in the future when he or she may lack the capacity to make healthcare decisions. Such statements usually take the form of advance refusal of specified treatments, but may also contain information about the patient’s values and beliefs.
At present there is no legislation covering advance directives in Ireland and there is very little relevant Irish case law to clarify their legal status, but the Medical Council1 provides the following guidance on the ethical position:
“An advance treatment plan has the same ethical status as a decision by a patient at the actual time of an illness and should be respected on condition that:
- the decision was an informed choice, according to the principles of informed consent ...,
- the decision covers the situation that has arisen, and
- the patient has not changed their mind.”
An advance treatment plan has the same ethical status as a decision by a patient at the actual time of an illness
there is any doubt about the validity or applicability of an advance decision, “you should make treatment decisions based on the patient’s best interests. In making such a decision, you should consult with any person with legal authority to make decisions on behalf of the patient and the patient’s family if possible.”2
End of life decisions
There is no obligation on you to start or continue a treatment, or artificial nutrition and hydration that is futile, even if such treatment may prolong life
When patients are seriously ill and lack the capacity to make medical decisions on their own behalf, clinicians may be obliged to make treatment decisions in the patient’s best interests. This might include choosing not to intervene if a treatment or procedure would be burdensome and with little benefit to the patient. The Medical Council advises:
“There is no obligation on you to start or continue a treatment, or artificial nutrition and hydration, that is futile or disproportionately burdensome, even if such treatment may prolong life. You should carefully consider when to start and when to stop attempts to prolong life, while ensuring that patients receive appropriate pain management and relief from distress.”3
However, decisions to discontinue a life-prolonging treatment or intervention (such as artificial nutrition and hydration) should be carefully discussed within the healthcare team and with the patient’s family. The substance of your deliberations should be documented in the patient’s notes, and if there is any doubt about the right course of action, the decision should be referred to the law courts (see Box 5).
Emergencies
Legal action against doctors providing treatment without consent in an emergency is extremely rare. In genuine emergencies, do not hesitate to provide immediately necessary treatment unless there are clear indications that the patient would object to the treatment.
They considered whether artificial nutrition and hydration constitutes medical intervention
Box 5: End of life decisions
In 1996, the Supreme Court heard the case* of a 45-year-old woman who had been in a near persistent vegetative state for 23 years and was being fed via a gastrostomy tube. Her mother, with the support of the rest of her family, applied to the High Court for permission to have the feeding tube removed and to allow life-threatening infections to take their course without antibiotic intervention. The High Court judge consented to this on behalf of the Ward, but the institution in which the Ward was living and the Attorney General appealed against the decision.
Four out of the five justices hearing the case upheld the High Court ruling. In their deliberations, they considered whether artificial nutrition and hydration constitutes medical intervention and whether its withdrawal would be in the Ward’s best interests.
The four justices who upheld the decision concluded that tube feeding does amount to medical intervention because it is intrusive and that withdrawing such intervention would be in the Ward’s best interests. They took the view that withdrawing artificial means of sustenance would not be tantamount to terminating her life; it would be allowing nature to take its course.
* In the Matter of a Ward of Court (withholding of medical treatment) [1996] 2 IR 73