Page last updated at 23:02 GMT, Wednesday, 19 May 2010 00:02 UK

Doctors urged to discuss dying days care

By Clare Murphy
Health reporter, BBC News

The GMC says doctors should not prejudge what certain patients want

Doctors are being urged to discuss end-of-life care with the terminally ill well in advance of their final days.

The General Medical Council, the profession's regulator, says early discussions can help avoid misunderstandings and conflict.

In new guidelines, the GMC says doctors should start from the assumption that life should be prolonged, although not at any cost.

Opportunities should also be sought to discuss organ donation.

It has long been the case that patients have a legal right to refuse treatment, but in recent years there has been controversy about the right of patients to be tube fed or hydrated right up until the point of death if doctors do not feel it is beneficial.

The GMC guidance states that in some cases providing nutrition or hydration at the end of life may cause unnecessary suffering.

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It also notes there are times when attempts at resuscitation with CPR may not be in a patient's best interests, as an inevitable death can be transformed into a traumatic experience.

A discussion about the benefits, burdens and risks should be had with the patient and those close to them.

In some cases it may be appropriate for the doctor to decide not to offer such treatment, but for the most part it will be the patient's request which is the "deciding factor", the new guidelines state.

The regulators do not address the issue of assisted suicide, which is illegal in the UK.

No preconceptions

It is hoped having the opportunity to discuss a care plan in advance should allay patients' concerns that they may be under- or over-treated in their final days and hours, and that all decisions will be directed by their doctor.

It will also allow patients to think about where they would like to die.

When the benefits, burdens and risks are finely balanced, the patient's request will usually be the deciding factor
GMC guidelines

The GMC said it received more than 500 written responses to its two-year consultation on the subject from a wide range of individuals and organisations including the religious groups, patient organisations and medical charities.

It highlights the need for doctors not to prejudge what care someone would want at the end of their life based on their age, disability or ethnic group - research suggests these people can receive poorer care as they die.

The guidance also sets out how those children with the capacity to understand should be involved in decisions about their treatment, and includes a new section on issues surrounding caring for very sick and premature babies which draws on existing recommendations.

There is also advice on doctors' responsibilities after a patient has died, and how they should approach conversations about organ and tissue donation. Demand for organs significantly outstrips supply and various initiatives are currently being examined to increase donation rates.

The chief executive of the GMC, Niall Dickson, said: "In the UK we have led the world in the care of patients at the end of life but we also know there is more that can be done.

"Every day at the front line of care doctors are having hard conversations with patients and their families and helping them to make incredibly emotional and difficult decisions. We hope this guidance will support them in providing the best quality of care and support."

The British Medical Association, which had been involved with the development of the guidelines, said: "We believe the GMC's new guidance is clear about the need to work with the patient or where appropriate their relatives or advocate to ensure that they are treated fairly, with dignity and without prejudice."

But the Alzheimer's Society said the issue of dementia in terminally ill patients, an increasingly common occurrence, had not been adequately addressed.

"'People with dementia have specific end of life care needs and too many are subjected to an undignified and unnecessarily painful death.

"We need dementia-specific guidance for clinicians if we are to ensure people with dementia get the dignity they deserve at the end of their lives."

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