Scotland increases effect of living will decisions

The Adults with Incapacity Act (Scotland) 2000 Act broadly covers the needs of patients’ wishes to be respected and refusals of treatment to be honoured. So although there is not a specific statutory provision for living wills (advance directives) such as in England & Wales, the effect is very much the same.

But new guidance is due to be implemented later this year which will potentially extend the authority of advance directives to emergency situations, according to newspaper reports.

Previous guidance has noted that the difficulty of assessing the validity and applicability of an advance directive in an emergency situation. If the patient is bleeding to death or suffering a heart attack, the general consensus has been to stabilise the patient first and look for an advance directive afterwards (the opposite would mean that the patient could die before the health team or paramedic discovered whether or not they wished to be kept alive. But now the possibility of notifying ambulances electronically as they rush to a patient in critical condition means that decisions can hopefully be made with a greater degree of certainty.

But it means extra care is needed (by patient and doctor) before a Do Not Resuscitate (DNR) order is authorised. Once made, it cannot be overruled by medics or relatives.

Simple? It might be for some who wish to end it all at the first opportunity. But the complexity of such advance decisions is perhaps well-illustrated by a profound if humorous comment frequently made by Professor Ken Mason, a medical ethicist who stressed the importance of advance directives. He was apt to start a discourse on the subject by pointing out that, should he collapse during the course of the lecture, he wanted the person who was best at cardiopulmonary resuscitation to bring him round immediately!

A blanket DNR order, made too early, could easily be ambiguous. If the heart attack should occur while one was still in comparatively good health, one would probably want resuscitated; if it occurred much later in life when there was little possibility of recovery (for instance, either due to advancing age or underlying disease), then it becomes a very different story. The directive must be very specific and clear, and deep consultation between doctor and patient is often the best way to arrive at an unambiguous instruction. Which means the effective usefulness of such new guidelines rests very much with the care and thoroughness with which they are implemented.

Full details of the Scottish Guidelines coming soon

Resources:
Newspaper report

Difficulties with advance decisions on resuscitation (article by Regnard & Randall)
Adults with Incapacity (Scotland) Act 2000
Withholding and withdrawing – guidance for doctors by the GMC
CAB Patients’ rights (Scotland)
CAB Patients’ rights (England)

Members of Exit: please refer to the members’ magazine (Exit Newsletter) Vol.29 No.2 for a full technical and non-technical guide to living wills.

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One Response to Scotland increases effect of living will decisions

  1. The need to write out one’s wishes is underscored by a recent study in the New England Journal of Medicine (http://content.nejm.org/cgi/content/short/362/13/1211) which emphasized that advance directives are indeed effective in ensuring that one’s wishes are honored. Many studies also indicate that the more detailed and complete your advance directive, the more likely your wishes will be followed. One comprehensive directive is the Lifecare Advance Directive (see: http://www.LifecareDirectives.com) — an international version of which is available for use in Scotland. The Center for Practical Bioethics also offers a useful planning workbook (see: http://www.practicalbioethics.org/cpb.aspx?pgID=986). Readers might want to explore these available documents further. Regardless of the forms you choose, everyone should make sure that their wishes are well documented and clearly spelled out. Doing so can save a great deal of unnecessary suffering and greatly reduce the burdens that families experience at these very difficult times, as well.

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