New guidance on clinically assisted nutrition and hydration launched
Last month saw the publication of new guidance, written by the BMA and RCP, and endorsed by the GMC, on Clinically Assisted Nutrition and Hydration (CANH) in adults who lack the capacity to consent in England and Wales. shuli [dot] levy [at] nhs [dot] net (Dr Shuli Levy), chair of the BGS Ethics and Law Special Interest Group (SIG), explains the implications of the new guidance
The BMA invited the BGS to be part of the core writing group, recognising the impact the guidance will have on our speciality. As chair of the Ethics and Law SIG, I have represented the BGS throughout the process, with a joint introductory session at last month’s conference in London which was well attended and received.
The guidance was initially drafted after a change in the law relating to individuals with a prolonged disorder of consciousness (PDOC; i.e. minimally conscious state or persistent vegetative state), which withdrew the imperative to consult the Court of Protection in withdrawing CANH for all PDOC cases. As the process got underway, it became clear that many other patients could be served by the guidance, to include those with neurodegenerative conditions and those with comorbidities and/or frailty who have suffered a significant brain injury.
The guidance is aimed at patients not expected to die imminently (within hours to days) – who may be at home, in a care home, or in hospital. Their likely disease trajectory is taken in to consideration, bearing in mind that this is often variable and unpredictable. Treatment in acute illness (e.g. nasogastric feeding to support recovery to a stable baseline) remains at the discretion of the treating team until the patient can be fully assessed for a decision regarding long-term CANH, where necessary.
Key points within the guidance that affect Geriatricians include:
- Decisions regarding CANH should be regularly reviewed in those who lack capacity to consent on this issue
- Best interest decision making should be clinician led, with input from the MDT and family/friends/carers of the patient
- Best interest decisions should be formally documented, including documentation from family and friends about the patient’s prior wishes and views – and lots of guidance on how to do this
- When considering commencing CANH, the guidance recommends following a clinician led best interest process
- When considering withdrawal of CANH, or not providing it, a second opinion should be sought after the best interest process has completed
- Trusts and CCGs in a region or local area should mutually support each other with training and resources. One suggested example for organising this could be local or regional multi-disciplinary special interest groups, in which individuals with an interest in CANH (eg Geriatricians!) reflect on cases as a group, and provide liaison and support.
- Trusts and CCGs could have a database of individuals able and qualified to provide a second opinion
- Mediation services should be available where there is conflict
- An application to the Court of Protection should be sought if disagreement persists
The guidance does not recommend commencing or continuing CANH in people with advanced dementia, where lack of sufficient oral intake reflects disease progression.
This position is consistent with that of the RCP in the Oral Feeding Difficulties and Dilemmas report (2010). All of the treatments and standards in the guidance are consistent with the GMC’s guidance on treatment and care towards the end of life.
The guidance recognises that implementation will be challenging for Trusts, CCGs and others, and have written extensive recommendations for implementation. They have also advised on access to training and support for doctors in primary and secondary care who are responsible for undertaking best interest decisions in this area, and provided training materials. These include short talks from several members of the working group and links to relevant research and other guidelines.
As well as the full guidance, the website has a quick reference guide (but please refer to full guidance where possible), a visual decision-making flow chart, an explanatory leaflet for family and friends and model best interest forms.
Throughout my time on the core writing group, I found the BMA to be highly responsive to input from the BGS Ethics and Law group and sensitive and thoughtful about how the guidance will affect our speciality, those working with us, our patients and their carers. I hope you can see this reflected in the guidelines. I’d be happy to answer any questions or respond to any comments you have – please shuli [dot] levy [at] nhs [dot] net (get in touch).
Links and further reading
Full guidance and supporting material:
Guardian opinion piece - 12 December 2018
Two other blogs from members of the writing group