Ethics England Wales

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Clinically-assisted nutrition and hydration guidance

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This guidance covers decisions to start, re-start, continue, or stop CANH for adults in England and Wales who lack the capacity to make the decision for themselves.

It covers previously healthy patients in vegetative state (VS) and minimally conscious state (MCS) following a sudden-onset brain injury, as well as the much larger group of patients who have multiple comorbidities, frailty, or neurodegenerative conditions in whom decisions about CANH are needed.

It updates and expands on existing guidance about life-sustaining treatment from the BMA, Royal College of Physicians (RCP), and General Medical Council (GMC), and should be used in conjunction with those.

Although the guidance applies to England and Wales only, many of the basic principles will be applicable to doctors working in Northern Ireland and Scotland. In these instances, doctors should not rely on this guidance alone, but should also refer to country-specific law and professional guidance.

Key topics covered

  • The legal context for decision-making
  • Who is the decision-maker, and who must be consulted?
  • Conscientious objections
  • Clinical assessments
  • Best interests assessments
  • Second opinions
  • Managing disagreement and uncertainty
  • Record-keeping
  • Governance and audit

How to use this guidance

The guidance is split into two parts:

  • General guidance which applies in all cases (part one); and
  • Specific guidance for the different categories of patients covered by the guidance (part two).

You are advised to read the whole of part one and the relevant section(s) of part two. Information in the appendices covers: 

  • practical guidance for best interests decision-making
  • a sample form for recording information and discussions about best interests
  • recommendations on implementation, training and support; and
  • detail about the legal background to decisions about CANH

You can also download the quick reference guide, which is a condensed summary of the full guidance. The quick reference guide should be read in conjunction with the main guidance, and not in isolation. 

You might find this helpful if you are coming to the topic for the first time; or, if you have more experience of decision-making, it can help as an aide memoire of the guidance in full.

Download full guidance 

Download the quick reference guide

Information for GPs

BMA members may receive a free printed copy of the guidance (while stocks last) by emailing [email protected] with their name, mailing address and membership number.

  • Endorsement of CANH guidance

    The following organisations were involved in the development of the guidance and have provided formal endorsement.

    The Nursing & Midwifery Council (NMC)

    The Nursing & Midwifery Council (NMC) welcomes this joint guidance from the British Medical Association (BMA) and Royal College of Physicians (RCP). The NMC provided comments and expressed support for the guidance during the written consultation phase, and believe that the general principles and standards are consistent with its own standards of proficiency.

    The BMA/RCP guidance does not set a threshold for NMC fitness-to-practise action, but is a valuable tool for guiding the decision-making of all members of the healthcare team.



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