Decision-making at
End-of-Life
Dr Mary Kiely
Consultant in Palliative Medicine
Calderdale & Huddersfield NHS
Foundation Trust
Ethical Principles
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Non-malevolence
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Beneficence
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Respect for autonomy
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Justice
Human Rights Act, 1998
Article 2
Right to life
3
Freedom from inhuman or degrading
treatment
8
Respect for privacy, family life
10
Freedom of expression
14
Freedom from discriminatory practice
Who makes treatment decisions?
Clinical decisions
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years of expertise
evidence-based practice
knowledge of risks and benefits
medical futility
Patient Participation
Discussions about proposed treatments and
outcomes:
• 40-80% cancer patients want active role
• only 10% feel they should have the major
role
• many opt to give their doctor authority
Communication issues
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As much, or as little, as is wanted
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Format and manner which are understood
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Honesty
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Breaking bad news as opposed to treatment
decision
Mental Capacity
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Presumed present

Best interests
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Proxy decision-makers
Decisions Relating to Cardiopulmonary
Resuscitation:
A Joint Statement from the BMA, the
Resuscitation Council (UK) and the RCN
October 2007
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Presumption in favour of CPR
Do not attempt CPR if it will not
restart the heart/breathing
Discussion about CPR with patients is
not always necessary
Communicating DNAR decisions
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‘…not necessary to initiate discussions
re CPR…but careful consideration should
be given as to whether or not to inform
the patient of the decision.’
Preferable to emphasise end-of-life
care in general, rather than specifics re
DNAR.
Discussion recommended
prior to documentation:
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When illness trajectory is uncertain.
In response to a patient or carer
request or question about CPR.
When the patient has made it clear that
they wish to be informed of all health
care decisions.
Discussion not appropriate
prior to documentation:

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Patient is aware they are dying and have
expressed a wish for comfort care.
Patient prefers not to discuss end-of-life
care, giving responsibility for decisions to
their doctor or carers.
The patient is clearly in the terminal phase
and the doctor believes that the harm of
discussion outweighs the benefits.
Take care with language used

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Avoid describing CPR as “doing
everything”
“Is that okay with you?” can be
interpreted as a request for permission
or consent.
Factors linked to non-survival/
non-successful CPR:
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advanced malignancy
immobility
pneumonia
renal failure
dementia
age over 70
hypotension
primary respiratory arrest
Decision-making at the
end-of-life
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Consider likelihood of treatment
success
Agree desired treatment outcomes
Limit treatment to quality of care
Involve patients with capacity
Communicate with family members
Present in terms of gains not losses
Useful questions for patients with capacity

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How do you feel things are going?
What do you feel is causing you the most
problem/bother at the moment?
How do you see the future?
Do you feel you have enough information on
what is happening/might happen in future?
Have you thought about where you’d like to be
if things take a turn for the worse?
The Role of Self Care
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It is important to reflect on end-of-life
discussions.
Giving of oneself emotionally can take
its toll.
Develop support mechanisms:
debriefing, collaborative team
relationships
communication skills training.