Thursday, December 12, 2013

Prolonged Disorders of Consciousness – New RCP Guidanc

Yesterday, the Royal College of Physicians launched new guidelines on the diagnosis and management of people with prolonged disorders of consciousness (PDOC), a term covering patients remaining in a coma, vegetative state (VS), and minimally conscious state (MCS) after a brain injury.  Of particular interest are chapters 4 and 5.

Section 4: Ethical and medico-legal issues

  • Introduction 
    • Ethical principles 
  • The Mental Capacity Act 2005 
    • Mental capacity in patients with PDOC 
  • Provisions within the Act to support decision-making for patents who lack capacity 
    • Health and Welfare Lasting Power of Attorney 
    • Court-appointed Welfare Deputy 
    • Independent Mental Capacity Advocate 
  • Process to establish ‘best interests’ 
    • The role of the healthcare team 
    • The role of the family 
  • A summary of key roles in decision-making 
  • Practical arrangements for best interests decision-making 
  • Ethical considerations – the subjective challenges 
    • What is it like to be in VS or MCS? 
    • The evidence on pain 
    • Decisions about life-sustaining treatments in PDOC
  • Applications to the Court of Protection 
    • Applications for withdrawal of CANH 
  • Other factors affecting referral to the Court of Protection 
    • Individual planning 
    • Clinicians and conscientious objection

Section 5: End-of-life issues

  • End-of-life planning 
    • The family role in planning end-of-life care
  • Decisions about life-sustaining treatment and ceiling of care 
    • ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions
    • Ongoing DNACPR decisions 
  • Withdrawing other life-sustaining treatments 
    • Permanent vegetative state
    • Permanent minimally conscious state 
  • Practical management of end-of-life care for patients with PDOC
    • Challenges for end-of-life care and place of death
    • End-of-life care following withdrawal of CANH 
    • Certification of death 
    • Suitable setting for end-of-life care 

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