The PPIW report ‘Increasing understanding and uptake of Advance Decisions in Wales’ highlights some important issues of particular relevance to Primary Care in Wales. The Mental Capacity Act (2005) should by now be very familiar to all health care professionals, especially GPs. Assessing capacity to make decisions is an integral part of our day to day work as General Practitioners, especially when you consider the changing demographics of the population we serve. Although not universally the case (we all know stories about ‘my granny who was 105 and still as sharp as a tack!’), increasing age and associated multiple co-morbidities are often associated with cognitive decline which will affect a person’s ability to make decisions. Decision making when an individual lacks capacity is very much part of our day job, and should be second nature to us.
This is why I am frequently surprised by the reaction of professional colleagues when I bring up the topics of capacity, best interest decisions and ADRTs. The responses are almost invariably confusion or trepidation. It is not only the public who are ill-informed about the role of the next of kin and the process of making best interest decisions when an individual lacks capacity, as this also applies to many health professionals. This confusion and fear increases significantly with regard to ADRTs. The legal intricacies of this particular aspect of the MCA, combined with the infrequency with which generalists come across such decisions and documents exacerbate the problems that arise from this poorly understood piece of legislation and its practical application.
The issues for GPs around ADRTs, and other forms of decision making related to lack of capacity, usually come back to the fact that we don’t want to ‘get it wrong’. The principle of ‘first, do no harm’ is ingrained in our profession. We frequently lament the case of the individual who received a futile treatment when there was information that suggested that is not what they would have wanted. By not arming ourselves with a good working knowledge of areas such as ADRT (and Advance Care Planning in general), we may actually be allowing such harm to occur through our inaction. Issues around sharing information about the existence and content of ADRTs, DNACPR (Do not Attempt Cardiopulmonary Resuscitation) decisions and Advance Care Plans are often cited as reasons against having them in the first place. But this is not a valid reason to ignore or discourage individuals from expressing their wishes about their care. This should motivate the Welsh Government and Health Service in Wales to develop an integrated solution to the issue of sharing ADRT and DNACPR decisions.
The recommendations of this report should be embraced by the Health Service in Wales, and Primary Care in particular, as they have the potential to have a significant positive impact on our patients and our own professional practise. However, it is clear that my profession will need much support and guidance to be able to contribute to delivering positive change in this area.
About the author: Dr Clifford Jones is a GP in Blaenau Gwent, a GP Trainer and Macmillan GP Lead for the Framework for Cancer in Primary Care. His clinical interests include Cancer and End of Life Care, and he has produced and delivered training on Palliative Care and Advance Care Planning for Nurses and GPs. He is the current Chair of the RCGP Wales End of Life Care Network.