Trinity Hospice and Palliative Care Services
Position statements on Common Ethical Dilemmas
Ethical dilemmas are common at the end of life and in hospice care in general. Such dilemmas can create
tension within professional teams and often lead to widespread misunderstandings.
As an organisation, Trinity Hospice and Palliative Care Services, has decided to make clear position
statements on a number of common and challenging ethical dilemmas.
Each position statement stands on its own and follows the same format.
Each statement is intended to work as a succinct guide on the issue contained in the title for members of
staff and users of our service.
Each statements take into account:
 Professional guidance from the General Medical Council (GMC) and Nursing and Midwifery Council
(NMC)
 Professional statements from the Association of Palliative Medicine for Great Britain and Ireland
 Statements from the Royal College of Physicians (RCP) and the Royal College of General Practice
(RCGP)
 The current law in England
 Opinions expressed by staff working in our service and the consensus of professionals working in
specialist palliative care
 Our assessment of the impact of the statement on patient care across the family of services that
make up Trinity Hospice and Palliative Care Services.
Statements cover
 Doctrine of Double Effect
 Advanced Care Planning
 Cardio-pulmonary Resuscitation at end of life
 Sedating Drugs at the end of life
 Information Governance and Confidentiality of Personal data
 Assisted Dying
 Withholding and Withdrawing Treatment (adult unit only)
 Individualised care plan for last days or hours of life
 Medication beyond license
Trinity Hospice and Palliative Care Services
Information Governance and Confidentiality of Personal Data
Statement
The organisation commits itself to keeping the minimum identifiable personal, information on
individuals that it needs to deliver care effectively and raise appropriate funds. The organisation
will keep clinical information separate from donor information. This may mean that the details of
one person may be held on two databases, at the same time.
Background
In order to deliver specialist palliative care to our local community the Trinity holds personal information on
patients and their families both electronically and in paper form. There can be tension between respecting
an individual’s right to keep personal information confidential and the need for the organisation to
communicate sufficient information to others to enable them to deliver safe and effective care or make
appropriate decisions.
Wherever possible we will ensure that the individual whose information needs to be shared knows what
information is being shared and with which organisations and the professionals groups who will access that
data.
Where there is uncertainty about the amount or kind of information that should be shared we will seek the
consent of the patient to do so, explaining clearly why this is being requested and the consequences of
withholding such information. The main exceptions to this will be where there are suspicions that a crime
may have been committed or there is a safeguarding issue when consent will not be sought in sharing that
information with the appropriate authorities
All personal information will be checked regularly for accuracy and kept securely with clear processes
around which staff can access which pieces of information.
No identifiable, personal information will be shared with anyone else including family members except with
the expressed permission of the individual concerned. If the individual concerned is unable to give their
consent then the senior doctor and nurse in charge of that patient’s care will seek to act in that individuals
best interests following the procedures laid down in the Mental Capacity Act.
All staff employed and volunteers used by the hospice will sign a code of conduct which includes a clear
statement around maintaining confidentiality.
The hospice has in place the necessary procedures to comply with the Data Protection Act 1998. The
Caldicott Guardian for the organisation is the Medical Director.
Any breach of an individual’s confidentiality by a staff member or volunteer will be treated as a serious
disciplinary offence.
The organisation has achieved and is committed to maintaining at least a level 2 compliance on the
Information Governance Toolkit which is the national framework for health and social care providers.
Susan Salt Medical Director
First Written October 2011
Reviewed April 2013, June 2014, August 2015
Next Review Date September 2016
Trinity Hospice and Palliative Care Services
Position statement on Cardio-Pulmonary Resuscitation (CPR)
Statement
Trinity hospice will ensure that all clinical staff are trained to provide basic cardio-pulmonary resuscitation
using external cardiac massage and where appropriate bag and mask breathing for both adults and
children.
Trinity Hospice will not perform advanced cardio-pulmonary resuscitation (including defibrillation and the
administration of medication to restart the heart) on anyone cared for within the hospice or anyone visiting
the hospice.
Clinical staff will discuss the issue of cardio-pulmonary resuscitation when a patient or someone close to
them brings up the issue. Staff will bring up the issue with patients and those important to them when it is
clinically relevant to do so (such as a patient with an implantable defibrillator or when a Do not attempt
resuscitation order is needed such as on discharge or transfer from the hospice).
Due to the duty of care placed on the ambulance service to take action if an individual becomes unwell, in
most circumstances, a patient being moved from the hospice to another care setting (usually home) by
ambulance must have a current “DNACPR” (Do not attempt cardio-pulmonary resuscitation) form in place.
Without such a form being completed prior to the ambulance journey any change in an individual’s
condition may lead to a hospital admission whether wanted or not.
Where a current DNACPR is needed one of the medical team will discuss the issue with the individual
patient (and those important to them) and explain why a DNACPR form may be applicable and what it
means.
A patient can decline to accept a DNACPR order, can ask for it to be revoked or reviewed at any time. This
will have no impact on any other aspect of their care. It will however commit the patient to being
transferred to hospital if CPR is commenced.
Background
Trinity Hospice has made the judgement that, because a sudden collapse of a patient with a cardiorespiratory arrest is very rare within our setting, the hospice is unable to ensure an adequate level of skill
in advanced cardio-pulmonary resuscitation skills amongst its staff.
Some people believe that cardio-pulmonary resuscitation is straightforward and successful in a significant
number of cases. Sadly this is not the case. Both basic and advanced cardio-pulmonary resuscitation can
be effective in patients with certain cardiac arrhythmias but it is a complex procedure which takes skill and
frequent practice to perform well.
Most requests for patients to have cardio-pulmonary resuscitation are based on the belief that not being
resuscitated also means that other treatments such as antibiotics for a chest infection will be withheld.
This is not the case. Declining cardio-pulmonary resuscitation is a very specific decision and will not affect
any other decisions about care.
Staff will make decisions about the appropriateness and likely success of basic cardio-pulmonary
resuscitation on an individual patient basis. If basic cardio-pulmonary resuscitation is undertaken it will
mean that the patient or visitor will be transferred to the local acute hospital by emergency ambulance for
stabilisation and further management.
Palliative care aims to neither prolong nor shorten life. Attempting to restart the heart of someone who is
suffering from a life limiting illness, of any cause, is unlikely to be successful and so, in most cases, is seen
as medically futile within the hospice setting and may cause unnecessary distress to the patient and their
family.
Hospice staff are willing to discuss decisions around cardio-pulmonary resuscitation with patients and/or
their representatives and will support a patient to choose to have basic CPR. Such a decision will be
reviewed with the patient and their representatives on a weekly basis, to ensure the choice to have CPR
remains valid.
Susan Salt Medical Director
First Written September 2011
Next Review Date September 2016
Reviewed April 2013, June 2014 , August 2015
Trinity Hospice and Palliative Care Services
Position statement on Assisted Dying
Statement
Trinity Hospice and Palliative Care Services will not seek to support any change in the legalisation
around the provision of assisted dying.
If the law in England is changed, Trinity Hospice and Palliative Care Services will not be involved
in the provision of delivering a lethal cocktail of medication to assist the death people under its
care.
Background
Whilst palliative care strives to enhance patient dignity and choice towards the end of life, the perceived
risk of providing assisted dying as a treatment option, within any part of the family of services that make
up the organisation, is that vulnerable people who are dying may feel that they have a duty to die in order
not to be a burden and to reduce the distress of loved ones.
Most requests to hasten death are expressions of distress and fear. As an organisation, we feel that,
allowing any part of the family of services that makes up the organisation, to provide assisted dying will
fundamentally undermine the trust between patients and staff which is a core part of the care provided by
the organisation. This view applies whether assisted dying is brought about through the prescription of
drugs that the patient takes, or through the administration of drugs by a third party, (with the patient’s
consent).
This statement makes no value judgment about assisted dying or the people who make requests for
assisted dying. The organisation recognises that some individuals may wish to pursue this option for
themselves in certain circumstances. Holding such views will not stop individuals from accessing the
service Trinity Hospice and Palliative Care Service provides as long as they meet our eligibility criteria and
recognise that the organisation will not be able to facilitate such an option in any way.
Susan Salt Medical Director
First Written Sept 2009 Reviewed Jan 2013, June 2014, August 2015
Next Review date September 2016
Trinity Hospice and Palliative Care Services
Position statement on withholding and withdrawing potentially life prolonging
treatments in the adult in-patient unit.
(This position statement does NOT apply to Brian House Children’s Hospice)
Statement for Adult Service ONLY
Trinity Hospice and Palliative Care Services will not commence any life-prolonging treatments such
as ventilation, chemotherapy or artificial feeding in the adult in-patient unit.
However if such life prolonging treatment has been started elsewhere the medical and nursing
staff will liaise with the patient and medical colleagues about the appropriateness of continuing
such interventions on a case by case basis.
The hospice will seek to stop any life-prolonging treatments which are deemed to be futile or
excessively burdensome to the patient. Such decisions will be made after careful discussion with
the patient and their representatives and will be made on a patient by patient basis.
Decisions about life prolonging treatments will always be discussed with the patient, when they
wish to be involved in such discussions, and have capacity to participate. Any patient shown to
have the ability to make such decisions will be supported in the decision they choose to make
even if that decision appears “unwise”.
Background
As an organisation, Trinity Hospice and Palliative Care Services accept that life has a natural end and that
there comes a point, for some people, when any medical treatments will either not prolong life or causes
more suffering than benefit. Decision making in such situations requires sensitive and effective
communication skills backed up with a sound knowledge of the options and likely consequences. The
organisation will ensure that staff have the appropriate knowledge and skill to undertake such discussion.
Professional staff working for Trinity Hospice and Palliative Care Services are under no legal obligation to
start or continue life-prolonging treatment when they, after careful consideration, believe the patient will
suffer more harm than good from it.
Stopping or starting potentially life prolonging treatment is not a form of assisted dying because the
intention is not to end life but purely to avoid additional, unnecessary suffering. Under such
circumstances, when a patient dies, it is from overwhelming disease, not from being denied futile or
excessively burdensome treatments.
Susan Salt Medical Director
First Written September 2009
Next Review September 2016
Reviewed April 2013, June 2014 , August 2015
Trinity Hospice and Palliative Care Services
Position statement on the use of sedating drugs at the end of life
Statement
Medication which is sedating in its effect will only be used within the family of services of Trinity
Hospice and Palliative Care Services to treat symptoms of agitation, restlessness and distress
alongside more specific interventions and/or medication that address the cause of such as pain
relief.
If sedating medication is used, it will be given at an appropriate dose tailored to the individual’s
needs in relation to the severity of their symptoms.
As an organisation, Trinity Hospice and Palliative Care Services believes that sedating medication
used in this limited and controlled way does not shorten life.
Background
Rarely, patients may experience distress when symptoms cannot be controlled even after exhaustive
attempts with specific interventions. In these circumstances, some patients may require sedating
medication to diminish awareness of their suffering.
All medication used for symptom control across the organisation, including the use of sedative medication,
is aimed at the relief of specific symptoms.
Sedation used across the family of services of Trinity Hospice and Palliative Care Services in this way is
sedation while the patient dies and not sedating the patient to death.
Morphine and related pain killing drugs are wholly unsuitable for use as sedation and will not be used for
this purpose within any part of the family of services that make up Trinity Hospice and Palliative Care
Services.
Susan Salt Medical Director
First Written Sept 2009
Reviewed Oct 2012, June 2014, August 2015
Next Review Date September 2016
Trinity Hospice and Palliative Care Services
Position statement on the doctrine of double effect
Statement
Trinity Hospice and Palliative Care Services does not accept that morphine, related drugs and
sedative drugs, when used appropriately to manage symptoms associated with end of life care,
hastens death.
As an organisation, Trinity Hospice and Palliative Care Services believes that the correct use of the
majority of drugs that are routinely used in palliative care address symptoms and have no impact
on length of life.
Background
The doctrine of double effect states that the risk of a potential known (foreseen), unintended
consequence or side effect of treatment is justified only if all the following criteria are met:
 The intended effect is good in itself
 The clinician’s intention is solely to produce the good effect
 The intervention is proportionate to the situation
 The good effect is not achieved through the bad effect
There is no credible research evidence to suggest that a patient’s life is shortened either by
opioids or sedatives when used in line with accepted palliative care practice.
Susan Salt Medical Director
First written Sept 2009
Reviewed April 2013, April 2015, August 2015
Review Date September 2017
Trinity Hospice and Palliative Care Services
Position statement on advanced care planning
Statement
All the family of services that make up Trinity Hospice and Palliative Care Services supports the
widespread use of advanced care plans and advance decisions to refuse treatment.
All the family of services that make up Trinity Hospice and Palliative Care Services will support
patients in advanced care planning. The hospice sees advance care planning as a process rather
than the result of a one off discussion and will support the patient and/or their representative with
the information they need, and ensure they have the time they need, to make such a plan.
Discussions about advanced care planning will be made in the context of the person, their
understanding of their condition, their wishes as well as local resources. Advanced care planning
will be undertaken in a sensitive, timely manner after honest communication with the patient and
those they choose to be part of such discussions.
With the consent of the individual advanced care plans will be shared with relevant organisations
involved in the delivery of that person’s care.
Background
Advance care planning requires sensitive, timely and honest discussion with patients and those they choose
to be involved in those decisions. The process should not be rushed but should recognise what may
happen to the individual as part of their illness journey, and should therefore be re-discussed and amended
if the patient’s wishes change.
Advanced care planning allows patients and carers to express their wishes and preferences about the kind
of care they would like to receive at the end of life. Advance care planning discussions help to clarify
decisions such as the location of end of life care and withholding or withdrawing certain treatments such as
cardio-pulmonary resuscitation, ventilation or artificial feeding.
However, there are a number of issues that need to be highlighted:
 Any advanced care plan must be voluntary.
 An advanced care plan will only come into operation when a patient loses capacity. Up until that
point, the patients’ contemporaneous views take precedence.
 Patients must be allowed to change their mind as their preferences are likely to evolve over a
period time.
 Under the terms of the Mental Capacity Act (in England and Wales), unless there is a properly
constructed advance decision to refuse treatment or appointed lasting power of attorney, the doctor
is bound to act in the best interest of the patients rather than only on the basis of a previously
expressed preference.
 Issues of equity and limits on local resources have to be acknowledged in attempting to meet
patient preferences.
Susan Salt Medical Director
First Written September 2009
Next Review Date May 2016
Reviewed April 2013, June 2014. August 2015
Trinity Hospice and Palliative Care Services
Position Statement on the use of an individualised care plan in the
last few days and hours of Life
Statement
All the family of services that make up Trinity Hospice and Palliative Care Services supports the
widespread use of prompts and frameworks to empower good care and open communication with
the person who is dying (if able) and those closest to them and to ensure that there is two way
dialogue.
The organisation acknowledges that the use any prompts and framework must be individualised to
the patient and those close to them and are dependent on excellent, honest and open
communication between staff the patient (where possible) and family.
Background
The goal of an individualised care pan at the last few days or hours of life is to ensure that a death is as dignified and
as peaceful as it can be.
The care plan asks professionals to consider with the patient (where possible) and their family (or those the patient
has nominated) the following when a person under their care appears to be getting worse.
 Could the person be dying
 If they could be dying, does this fit with what is known to be wrong with the patient such as having advanced
cancer, heart failure or end stage respiratory problems.
 If they could be dying have all reversible causes for the deterioration in the person’s condition been
considered and managed appropriately.
An individualised care plan for the last days or hours of life should only be started if professional, patient (where able)
and family agree that the person may be approaching the end of life.
The plan asks staff to review the care of the patient on a regular basis. If the situation changes and new information
comes to light or the person appears to improve the plan should be revised.
The plan MUST be based on the unique needs of the patient approaching end of life and those close to them. The
plan does not tell a patient or professional or a family member what should be done, rather the pathway encourages
discussion about what seems to be the right thing to do for this person, at this moment.
Such a discussion will involve the review of how useful certain interventions are at this stage in a person’s illness,
including:
 Prescribed medications including medication to control high blood pressure, high cholesterol and diabetes
 Tests and measurements such as taking a patient’s temperature or blood pressure or doing blood tests
 The most appropriate way to keep the patient physically as comfortable as possible. This might include some
or all of the following:
o Providing regular mouth care
o Offering small sips of fluid, tastes of soft food such as ice cream or sorbet
o Using a subcutaneous syringe driver to make sure key medicines to control symptoms are
administered even when the patient is too tired to take them by mouth
o Using an appropriate bed and pressure relieving mattress etc
o Putting a catheter into the bladder so the person does not have to use a bed pan or commode
 Whether fluids should be given artificially when a patient is unable to eat or drink
 The spiritual or religious needs of the patient and those closest to them
 Clear agreement around which members of staff are responsible for reviewing the patient and meeting up
with the family. This agreement should include general agreements around mutually convenient meeting
times, frequency and length.
Susan Salt Medical Director
First Written May 2013
Reviewed June 2014, December 2014, August 2015
Next Review Date September 2016
Trinity Hospice and Palliative Care Services
Position Statement on the use of drugs beyond licence in palliative care
Statement
Trinity Hospice recognises that the use of drugs beyond licence is both necessary and common in
palliative care and should be seen as a legitimate aspect of clinical practice.
Prescribing unlicensed may be necessary where:
 There is no suitably licensed medicine to meet the patient need
 A medicine is licensed for use in one group and is used in another group
 Dosage specified for a licensed medicine would not meet the need of the patient
 The patient needs a medicine in a formulation that is not specified in an applicable licence
 A suitably licensed medicine that would meet the patient’s need is not available e.g. a
temporary shortage
 As part of a properly approved research project
It is expected that patients will be made aware that they are taking a medication beyond its UK
licence and the reasons for this.
Background
All medication available from legitimate sources, whether licensed or unlicensed and prescribed by an
authorised practitioner must comply with strict manufacturing, safety and reliability tests.
The term unlicensed is used to describe medicines that are used outside the terms of their UK licence or
which have no licence for use in UK. This does not mean the medicine is ineffective or has failed safety
tests. Rather it reflects the fact that no pharmaceutical company has submitted a request to the licensing
authority to license its use. This is a costly and lengthy procedure which most companies will only
undertake of there is an advantage to them to do so.
Choice of treatment requires partnership between patients and healthcare professionals. Healthcare
professionals involved in prescribing, dispensing and administering drugs beyond licence should select
drugs that offer the best balance of benefit against harm for any given patient.
All clinicians working in any capacity within the hospice will be expected to ONLY offer therapeutic practices
that are underpinned by evidence and advocated by a responsible body of professional opinion.
When an unlicensed medicine is prescribed the clinician must:
 Be satisfied that there is sufficient evidence or experience using the medicine to demonstrate safety
and efficacy
 Take responsibility for prescribing the medicine and for overseeing the patient’s care, monitoring
and follow up or ensure arrangements for another suitable doctor to do so
 Make a clear accurate and legible record of all medicines prescribed
 Where a clinician is NOT following common practice, the reasons for prescribing an unlicensed
medicine and explicit account of the potential risks and benefits of the course of action followed.
Susan Salt Medical Director
First Written May 2014
Reviewed August 2015
Next Review Date December 2017