{"id":3187,"date":"2017-07-14T07:51:09","date_gmt":"2017-07-14T06:51:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3187"},"modified":"2017-07-27T07:30:51","modified_gmt":"2017-07-27T06:30:51","slug":"guest-post-withdrawing-life-prolonging-treatment-in-the-patients-best-interests-the-implications-of-briggs","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/07\/14\/guest-post-withdrawing-life-prolonging-treatment-in-the-patients-best-interests-the-implications-of-briggs\/","title":{"rendered":"Guest Post: Withdrawing Life-Prolonging Treatment in the Patient\u2019s Best Interests: The Implications of Briggs"},"content":{"rendered":"<p><em><strong>Guest Post: Jenny Kitzinger, Celia Kitzinger and Jakki Cowley<\/strong><\/em><\/p>\n<p><em><strong>Paper: \u00a0<a href=\"http:\/\/jme.bmj.com\/content\/43\/7\/446\">When \u2018Sanctity of Life\u2019 and \u2018Self-Determination\u2019 clash<\/a><\/strong><\/em><\/p>\n<p>In a recent landmark judgment in the Court of Protection (<a href=\"http:\/\/www.bailii.org\/ew\/cases\/EWCOP\/2016\/53.html\"><em>Briggs v Briggs<\/em> [2016] EWCOP 53<\/a>), a judge authorised withdrawal of life-prolonging treatment from a minimally conscious patient with potential for further recovery.\u00a0 <a href=\"http:\/\/jme.bmj.com\/content\/43\/7\/446\">Our article in the\u00a0<em>Journal of Medical Ethics<\/em><\/a> addresses the implications of this judgment, highlighting its potential to strengthen compliance with the Mental Capacity Act 2005, and the delivery of person-centred care.<\/p>\n<p>How this will work in practice is another question.<\/p>\n<p>We have supported families (CK and JK) and represented patients (JC) in a series of cases \u2013 several of which have reached court \u2013 in which families sought treatment withdrawal and doctors refused.\u00a0 We know many families who believe that their brain-injured relative would not want to receive on-going life-prolonging interventions. It usually takes years for families to come to this view and even longer to communicate it to doctors. Some health care professionals can be dismissive \u2013 or even hostile \u2013 when families speak up.\u00a0\u00a0 Even when doctors acknowledge that a patient will never regain consciousness, some have ethical objections to withdrawing treatment from a clinically stable patient.\u00a0 It feels, they say, like \u2018euthanasia\u2019.<\/p>\n<p><!--more--><\/p>\n<p>An ethical imperative to give treatment is experienced even more acutely, by some doctors, when the patient may make some degree of \u2018progress\u2019 \u2013 perhaps recovering consciousness and the ability to interact with others. The treating clinician in the <em>Briggs <\/em>case was firmly of the view that it would be unethical to withdraw treatment from a patient whose level of consciousness might improve over time.\u00a0 This view was not supported by the Court of Protection judgment.<\/p>\n<p>The judge, Charles J emphasised the importance of finding out what <em>the patient<\/em> would have wanted in their current situation and said that if this \u201ccan be ascertained with sufficient certainty it should generally prevail over the very strong presumption in favour of preserving life\u201d (para. 62(ii)).\u00a0 \u00a0After hearing evidence provided by Mr Briggs\u2019 family and friends, he concluded that\u00a0 &#8211; although Mr Briggs had never specifically said that he would not want a feeding tube if he were to be in a minimally conscious state &#8211; it was clear from what he had said about related matters, and from the values he displayed in how he lived his life, that he would have refused this treatment. The judge therefore authorised treatment withdrawal.<\/p>\n<p>In the six months since the <em>Briggs<\/em> judgment, we\u2019ve discussed it with many clinicians and used it in training with legal and healthcare professionals \u2013 both in relation to advance decisions to refuse treatment and in relation to best interests decision-making.\u00a0 We\u2019ve found some healthcare professionals express relief that the law supports a person-centred, ethical position that accords with their own sense of how they want to work. \u00a0However we have also encountered resistance from some clinicians who do not want to give much weight to the patient\u2019s views when these conflict with their own sense of what is right.<\/p>\n<p>Several (senior) doctors have told us that they would deliver CPR in the best interests of a patient who had capacitously refused it moments before her collapse.\u00a0 Others have said that they would give treatments in the best interests of a patient who had refused them via an Advance Decision (AD), at least pending legal advice as to its validity and applicability.\u00a0 When we point out that giving treatment to a capacitous patient who has lawfully refused (contemporaneously or in advance) constitutes assault, battery or civil trespass, they say that the Mental Capacity Act gives sufficient \u2018wiggle room\u2019.\u00a0 For example, no liability is incurred for giving treatment unless you are \u201csatisfied\u201d that an AD is valid and applicable (s. 26(2) <a href=\"http:\/\/www.legislation.gov.uk\/ukpga\/2005\/9\/contents\">Mental Capacity Act<\/a>) \u2013 and they would not be \u2018satisfied\u2019 without legal advice.<\/p>\n<p>Treatment refusals conveyed second-hand via families who are extrapolating what the person would want from their prior values, wishes, feelings, and beliefs \u2013 rather than reporting specifically stated refusals \u2013 stand even less chance of being respected (or even acknowledged).<\/p>\n<p>We recently attended a best interests meeting at which two consultants refused even to consider stopping a treatment (the feeding tube) provided to a profoundly brain-injured patient who was showing signs of improvement. Despite acknowledging that the person would be very unlikely to recover to a quality of life he\u2019d have considered worthwhile, they said it would be unethical not to give treatment. One consultant, who we challenged by citing the <em>Briggs<\/em> case, said it \u201cwasn\u2019t relevant\u201d because Mr Briggs had been minimally conscious and so the judge\u2019s reasoning could not be generalised to her patient who was above minimally conscious.<\/p>\n<p>So, despite the clear practical and policy implications of <em>Briggs<\/em> we\u2019re concerned that the system continues to side-line what the patient would have wanted in favour of a taken-for-granted implicit sanctity-of-life approach. \u00a0\u00a0Yet, the judgment does send out a clear signal, underlining the weight that should be given to patients\u2019 wishes; what is needed for this to work in practice is increased training and support for health care professionals in putting the patient\u2019s values (rather than their own) at the heart of decision-making.<\/p>\n<p>&nbsp;<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Guest Post: Jenny Kitzinger, Celia Kitzinger and Jakki Cowley Paper: \u00a0When \u2018Sanctity of Life\u2019 and \u2018Self-Determination\u2019 clash In a recent landmark judgment in the Court of Protection (Briggs v Briggs [2016] EWCOP 53), a judge authorised withdrawal of life-prolonging treatment from a minimally conscious patient with potential for further recovery.\u00a0 Our article in the\u00a0Journal of [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/07\/14\/guest-post-withdrawing-life-prolonging-treatment-in-the-patients-best-interests-the-implications-of-briggs\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,2153,591],"tags":[],"class_list":["post-3187","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-guest-post","category-life-and-death"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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