Decisions to withdraw clinically assisted nutrition and hydration (CANH) from patients in permanent vegetative state (PVS) or minimally conscious state (MCS) following sudden onset profound brain injury
Interim guidance for health professionals in England and Wales from the BMA, Royal College of Physicians (RCP) and General Medical Council (GMC)
The case of Tony Bland in 1993 (who was in a permanent vegetative state (PVS) after being injured at the Hillsborough Stadium Disaster) established that clinically assisted nutrition and hydration (CANH) is a form of medical treatment that can be withdrawn in some circumstances. In that case it was also held that, in England and Wales, prior court approval should be sought for the withdrawal of CANH in all such cases.
There have been a number of recent legal developments that change the way such decisions are made - including recent court judgments and the withdrawal of the Court of Protection’s Practice Direction 9E. The interim guidance has been published in response to these legal developments and outlines what we consider to be good clinical and professional practice in this area.
About this guidance
These decisions are clinically, legally and ethically challenging for clinicians. This document is intended to provide clear current guidance on good practice for doctors and other clinical professionals pending publication of the new guidance, and for this reason is described as "interim".
For the avoidance of doubt, our understanding of the current legal situation is that it is not mandatory to make an application about the withdrawal of CANH to the Court of Protection, where both the clinical team and those close to the patient are in agreement that it is not in the patient’s best interests to continue that treatment.
Where we refer to seeking legal advice in the document, this is to highlight in particular the need for caution where there is uncertainty about the circumstances of the case or whether the steps set down in the guidance have been followed. We are also aware that the Supreme Court is currently considering this issue, and clinicians are therefore advised to continue to check the BMA website for the up-to-date legal position.
We are currently working with the Royal College of Physicians and the General Medical Council to issue updated and in-depth guidance on good clinical and professional practice for making decisions about CANH, which we are hoping to publish in Autumn 2018. As part of this process we are currently carrying out a targeted consultation exercise amongst those who are involved with making or implementing these decisions, or who are otherwise affected by them (including relevant patient support groups and some families with experience of these decisions).
The interim guidance covers:
- The latest legal developments
- Whether and when there is a requirement to seek court approval
- Assessment of levels of responsiveness and awareness
- The Mental Capacity Act and best interests decision making
- Conscientious objection
- Seeking a second clinical opinion
- Recording decisions
- Reviewing decisions
Download the interim guidance