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  • Clinically-assisted nutrition and hydration (CANH) and adults who lack the capacity to consent Guidance for decision-making in England and Wales

  • Endorsed by the General Medical Council

    ‘We welcome this joint guidance which will support doctors in making ethically and legally sound decisions in the interests of patients. It provides practical advice to support decision-making in a complex, sensitive area of practice. As part of the BMA advisory group, we consider that the general principles and standards are consistent with our own guidance on Consent (2008) and Treatment and care towards the end of life (2010). This guidance is a valuable tool for healthcare staff, rather than a rule book, and it is not intended to set a threshold for GMC fitness-to-practise action.’ General Medical Council, 2018.

  • 1

    Acknowledgements

    The development of this guidance was overseen by a core group made up of representatives of the British Medical Association, Royal College of Physicians, and General Medical Council and a number of experts appointed to advise the group on the basis of their expertise. We are indebted to them for the considerable time and knowledge they gave in producing this guidance.

    Dr John Chisholm CBE, Chair of BMA Medical Ethics Committee (Chair of the Core Group) Sharon Burton, Head of Standards and Ethics, GMC Ruth Campbell, Senior Policy Advisor (Medical Ethics and Human Rights), BMA Dr Chris Danbury, Consultant in Anaesthetics and Intensive Care Veronica English, Head of Medical Ethics and Human Rights, BMA Professor Celia Kitzinger, Co-Director, Coma and Disorders of Consciousness Research Centre, Cardiff University Dr Shuli Levy, Consultant Geriatrician and General Physician Paul McGough, Senior Associate (Healthcare Regulatory Team), DAC Beachcroft Alex Ruck Keene, Barrister, 39 Essex Chambers Professor Lynne Turner-Stokes MBE, Consultant in Rehabilitation Medicine, Royal College of Physicians Jessica Watkin, Policy Manager (Standards and Ethics), GMC

    Thanks are also due to the following individuals and organisations who were part of the wider professional consultative group, who were consulted during the development of the guidance, and who commented on earlier drafts. Whilst their contributions were invaluable in helping to inform our views, it should not be assumed that the guidance reflects the views of all those who contributed.

    Dr Judith Allanson, Consultant in Neurorehabilitation Yogi Amin, Irwin Mitchell Dr Idris Baker, Association of Palliative Medicine Ian Barker, Medical Defence Union Jim Beck, Office of the Official Solicitor Dr Dominic Bell, Consultant in Intensive Care/Anaesthesia Victoria Butler-Cole, 39 Essex Chambers Naomi Campbell, Royal College of Nursing Jakki Cowley, Empowerment Matters Dr Stephanie de Giorgio, BMA General Practitioners Committee Department of Health and Social Care Bridget Dolan QC, Serjeants’ Inn Chambers Dr Aaron D’Sa, Specialty Registrar in Anaesthetics and Intensive Care David Edwards, Office of the Official Solicitor Dr Karen Elliott, Co-Managing Director of Gill-Thwaites & Elliott Consultants Professor the Baroness Ilora Finlay, Mental Capacity Forum Dr Helen Fidler, BMA Consultants Committee Professor Rob George, Professor of Palliative Care Professor Robin Gill, Emeritus Professor of Applied Theology Professor Raanan Gillon, Emeritus Professor of Medical Ethics Helen Gill-Thwaites MBE, Co-Managing Director of Gill-Thwaites & Elliott Consultants Katie Gollop QC, Serjeants’ Inn Chambers Dr John Gorst, Consultant in Intensive Care Joan Goulbourn, Senior Advisor Mental Capacity Policy, Ministry of Justice Dr Marion Gray, Consultant Psychiatrist Dr Zoë Greaves, Deputy Chair of BMA Medical Ethics Committee Dr Andrew Hanrahan, Consultant in Neurorehabilitation Dharinee Hansjee, Royal College of Speech and Language Therapists Susan Hardie, Office of the Official Solicitor Professor Richard Huxtable, Professor of Medical Ethics and Law, Centre for Ethics in Medicine, University of Bristol Suzi Kerrell-Vaughan, Independent Neurological Providers Association

  • 2 British Medical Association/Royal College of Physicians

    Dr Jatt Khaira, British Association of Stroke Physicians Professor Jenny Kitzinger, Co-Director, Coma and Disorders of Consciousness Research Centre, Cardiff University Gavin Knox, NHS Wales Michelle Kudhail, Independent Neurological Providers Association Dr Julie Latchem-Hastings, Research Associate, Coma and Disorders of Consciousness Research Centre, Cardiff University David Lock QC, Landmark Chambers Paula Mansell, Care Quality Commission Professor David Menon, Head of Division of Anaesthesia, University of Cambridge Sophy Miles, Doughty Street Chambers Michael Mylonas QC, Serjeants’ Inn Chambers Naeem Nazem, Medical and Dental Defence Union of Scotland Dr David Nicholl, Association of British Neurologists Dr Zoe Oliphant, Clinical Fellow, Care Quality Commission Camilla Parker, Partner, Just Equality Dr Marina Platts, Consultant in Neurorehabilitation Rebecca Raeburn, Royal College of Occupational Therapists Sophia Roper, Serjeants’ Inn Chambers Katie Scott, 39 Essex Chambers Caroline Shehu-Pearce, Barts’ Health, Palliative Care CNHS/Royal College of Nursing Dr David Smithard, Consultant in Elderly Medicine Dr Alison Stroud, Royal College of Speech and Language Therapists Professor Derick Wade, Professor and Consultant in Neurological Rehabilitation Dr Krystyna Walton, Consultant in Neurorehabilitation Dr Bee Wee, Consultant in Palliative Medicine Mr Robert Wheeler, Consultant Surgeon, Director of Clinical Law, University Hospitals Southampton

    We would also like to thank the many individuals and organisations who provided advice and who commented on an earlier draft of the guidance. Again, it should not be assumed that the guidance reflects the views of all those who contributed.

    Alzheimer’s Society Kiran Bhogal, Partner & Head of Healthcare, Hill Dickinson LLP British Dietetic Association British Geriatric Society British Society of Rehabilitation Medicine Catholic Medical Association (UK) Sir William Charles Professor Hannah Cock, Professor of Epilepsy and Medical Education, St George’s, University of London Professor John Coggon, Professor of Law Dr Peter Critchley, Consultant in Neurology and Rehabilitation Medicine Compassion in Dying Jane Dale, Healthcare Inspectorate Wales Dementia UK Faculty of Intensive Care Medicine Health Education England Hospice UK Huntington’s Disease Association Dr Judith Ibison, Reader in Primary Care, St George’s, University of London Intensive Care Society Professor Chris Jones, Deputy Chief Medical Officer for Wales Dr Stephen Lewis, Consultant Gastroenterologist Dr Jonathan Martin, Consultant in Palliative Medicine Jill Mason, Mills & Reeve LLP Medical Ethics Alliance Medical Protection Society Nursing and Midwifery Council

  • 3CANH and adults who lack the capacity to consent – guidance for decision-making in England and Wales

    UK Parkinson’s Excellence Network Dr Catherine Millington-Sanders, Royal College of General Practitioners Dr Lucy Series, Wellcome Research Fellow and Lecturer in Law Dr Claire Stark Toller, Consultant in Palliative Medicine Amanda Swain, Vice Chair and Policy Officer, UK Acquired Brain Injury Forum Dr Andrew Wilcock, Clinical Reader in Palliative Medicine and Medical Oncology All those who attended the consultative session on the guidance at the Independent Neurorehabilitation Providers Association conference, July 2018 All members of BMA committees and BMA Council who commented on the draft guidance All BMA members who contributed their views at focus groups in London and Cardiff, July 2018.

    Two other organisations participated in the consultation but have asked not to be listed here.

    We are particularly grateful to the individual family members with experience of decision-making around CANH who shared their experiences with us.

    This guidance is published under the auspices of the BMA Medical Ethics Committee which considered drafts at various stages of its development. The MEC’s membership for the year 2017-2018 was:

    Dr John Chisholm CBE (Chair), General practice, London Dr Hannah Barham-Brown, junior doctor, London Dr Charlie Bell, junior doctor, London Dr Iain Brassington, Bioethics, Manchester Dr Mary Church, General practice, Glasgow Professor Bobbie Farsides, Clinical and biomedical ethics, Brighton Professor the Baroness Ilora Finlay, Palliative medicine, Cardiff Professor Robin Gill, Theology, Canterbury Professor Raanan Gillon, General practice (retired) and medical ethics, London Dr Zoë Greaves (Deputy Chair), GP trainee, South Tees Professor Emily Jackson OBE, Medical law and ethics, London Dr Surendra Kumar, General practice, Widnes David Lock QC, Barrister, London Dr Helena McKeown, General practice, Salisbury Dr Mary Neal, Medical law and ethics, Glasgow Professor Wendy Savage, Obstetrics and gynaecology (retired), London Professor Mona Siddiqui OBE, Theology, Edinburgh Dr M E Jan Wise, Psychiatry, London

    Ex officio members Dr Andrew Dearden, treasurer Dr Anthea Mowat, chair of the representative body Dr Chaand Nagpaul CBE, chair of council Sir John Temple, president

  • 4 British Medical Association/Royal College of Physicians

    Contents

    Executive summary ................................................................................................................................. 6

    Figure 1: The decision-making process...........................................................................................12

    1. The aim and scope of this guidance ..