El declive del Imperio y el resurgimiento de Turquía

In England and Wales the Mental Capacity Act (MCA) provides a legal framework for decision-making for patients who lack the mental capacity to make a decision

(Department of Health, 2005). The GMC’s guidance for decision-making at the end-of- life for patients who lack mental capacity is consistent with the MCA (GMC, 2010). The MCA is underpinned by core principles, one of which is known as the ‘best interests’ principle. It states that: ‘an act done, or decision made, under this Act for or on behalf of a

person who lacks capacity must be done, or made, in his best interests' (Department for

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The term ‘best interests’ is not defined in the MCA but the MCA Code of Practice

provides guidance about how a decision-maker should work out the bests interests of a person who lacks the mental capacity to make a decision. This guidance consists of a checklist of factors to be considered by decision-makers and it emphasises that decision- makers must take into account all relevant factors related to the decision, not simply those they think are important. This means that healthcare professionals must consider more than the medical or clinical details of the case when making decisions. The

following points are recommended as important steps when trying to work out the best interests of a person who lacks capacity to make a particular decision (Department for Constitutional Affairs, 2007):

• The person should be encouraged to be involved in the decision as far as possible. • Relevant information (things important to the person who lacks capacity) should

be identified and taken into account.

• The person’s views (including past and present wishes and feelings, their beliefs and values) should be considered and documented.

• Assumptions should not be made about the person on the basis of their age, appearance, condition or behaviour.

• The person should be assessed for whether they might regain capacity in the future and whether the decision could be delayed until then.

• If the decision concerns life-sustaining treatment it must not be motivated by a desire to bring about the person’s death and assumptions should not be made about the person’s quality of life.

• Where practical and appropriate the decision-maker should consult the views of relevant others (such as those involved in caring for the person, close relatives or friends) for their opinions about the person’s best interests.

The code of practice states that when decision-making involves the provision of medical treatment the doctor or member of the healthcare staff responsible for carrying out the particular treatment is the decision-maker. In the event of disagreements over what is

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‘best’ for the patient, the MCA Code of Practice advises the decision-maker to carefully balance the varying concerns and opinions in order to decide between them. However, ultimate responsibility for making a decision lies with the decision-maker. In the case of ongoing disagreement a second opinion, a ‘best interests’ case conference, or mediation are possible options for resolution. Only if other attempts to resolve the dispute have failed is the court involved (Department for Constitutional Affairs, 2007).

The MCA guidance is underpinned by the important principle of respect for the patient’s autonomy. Though the patient is unable to make the decision, the substitute decision- maker is to seek to determine the patient’s likely wishes as far as is practically possible and to make a decision on their behalf which respects such wishes and values. The MCA presents this practice as a rational and practical process whereby the decision-maker collects relevant information and then weighs up the pros and cons in order to make a well-reasoned decision. However, some have suggested that reality may be rather more complex (Dunn et al., 2007). While the Code of Practice states that assumptions should not be made about the patient and that the patient’s beliefs and values are to be

considered, it makes no mention of the decision-makers beliefs and values which may impact on the decision made. Throughout the ‘best interests’ decision-making process the decision-maker has to weigh up the various opinions and options. However, the Code of Practice offers little guidance about how this ought to occur e.g. how much weight should be given to different opinions. While the MCA provides a clear and helpful set of legal guidance for decision-making, it appears that the ‘best interests’ decision- making process presents decision-making as a rational, straight-forward and neutral endeavour. Yet, the reality of clinical practice can be rather different as will be described in Chapter Seven.

3.6 Conclusion

In this chapter I highlighted and discussed recent events relevant to decision-making and care at the end-of-life, along with current policy and legislation guiding such

practice. Furthermore, I considered some of the principles underpinning current policy. In doing this I sought to place the practice of end-of-life care today within a current context. In the next and final background chapter, I explore the literature findings

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related to the practice of decision-making and care at end-of-life in order to gain insight into the varied perspectives of patients, families and healthcare professionals and to understand the challenges involved in providing good care for dying patients and their families.

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End-of-Life Care in Hospital

Having considered the history of end-of-life care in hospitals and recent events

impacting on the practice of end-of-life care and current policy, in this chapter I review the relevant literature on end-of-life care in hospital. First, I consider the question ‘what is care?’ and how this has been discussed in the literature. Second, I explore the

literature which describes the perspectives of patients, relatives and staff on end-of-life care in hospital. Third, I analyse the literature on key aspects which are seen to be central to good care: decision-making and communication. In this chapter I outline the relevant findings in the literature in order to set the scene for the findings of this research study. The literature concerning end-of-life care encompasses many disciplines including medicine, nursing, philosophy and sociology and therefore this literature review is broad and encompassing findings from these different disciplines. In this chapter I outline and critique the relevant literature in order to set the scene for the findings of this research study.