Synopsis
Integrate symptom relief, patient values, legal authority and proportionate treatment decisions near the end of life, including withholding or withdrawing treatment, uncertainty, disagreement and continuity across care settings.
- Recognise dying while testing reversible explanations where this could change care. Uncertainty should be named, reviewed and communicated rather than concealed behind a categorical prognosis.
- An adult with capacity decides among clinically appropriate options and may refuse life-sustaining treatment. A request does not oblige clinicians to provide treatment that cannot meet the patient’s needs.
- When capacity is absent, use the relevant jurisdiction’s best-interests or benefit framework, check advance decisions and proxy authority, and consult those close to the patient about wishes and values.
Reasoning priorities
Identify treatable contributors and the likely outcomes of each option.
Use clinical trajectory, response, comorbidity and function while stating uncertainty. Prognostic tools may inform estimates but cannot define an individual’s values or automatically decide treatment.
Worked reasoning
A 60-year-old patient with end-stage neuromuscular disease has capacity, finds ventilation intolerable and persistently asks for it to stop after understanding that death may follow soon.
- Confirm capacity, voluntariness and stable understanding; explore coercion, depression, symptom fears and whether modifications could meet the patient’s goals.
- Explain the likely course after withdrawal, offer a second opinion and agree a detailed plan for breathlessness, anxiety, family presence and staff roles with palliative specialists.
- Recognise that respecting a capacitous refusal of treatment is legally and ethically distinct from intending death; document the patient’s decision and the clinical plan.
- Final action: withdraw ventilation in the agreed setting while providing proportionate anticipatory symptom treatment and continuous support.
- Verification: monitor comfort closely, adjust treatment to observed symptoms, support relatives and staff, and document the course and communication.