Within the immediate surgical team
Non-consultant grade surgeons
As a non-consultant grade surgeon you should support patients to make decisions within the framework described in Section D with the support of the consultant surgeon responsible for the care of the patient. All significant decisions made in the best interests for patients lacking capacity should be made in conjunction with the responsible consultant surgeon, for example, decisions to undergo or not to undergo potentially life-prolonging surgery.
As a consultant surgeon, you should provide adequate supervision and support to junior and non-consultant grade surgeons. The best interests of the patient should always be put first whilst facilitating the education of junior surgeons in dealing with the ethical issues faced at the end of life. You should ensure that the opinions of the team are taken into account when supporting patients with decision making. In particular, when making decisions for patients lacking capacity at the end of life, you should always seek the opinions of others involved in the care of the patient as they may have different insights into what could be in the best interests of the patient.
You should ensure that when you are not available there is a full and explicit handover for the assessment, treatment and continuing care of patients. This handover should include the patient’s wishes and preferences for the end of life, where it is expected.
With other members of the healthcare team
Surgeons have a duty to ensure that they communicate effectively with other members of the healthcare team to avoid fragmented care, which can be a source of frustration to those nearing the end of life. When considering appropriate treatment in the context of the likely prognosis and preferences of patients, such communication may include seeking guidance from the specialist palliative care team. However it’s important to ensure that referral to palliative care is not a replacement for continued support from surgeons and that surgeons should continue to be involved in communication and decision making.
The multi-disciplinary team (MDT) meeting
For surgeons, many of the patients they see nearing the end of life may be eligible for discussion at an MDT meeting. In the context of surgery, this MDT is likely to be a cancer one but many other MDT types exist and should be used where appropriate.
In line with The Characteristics of an Effective Multidisciplinary Team, members of an MDT should be familiar with the patient’s history, views and preferences when making recommendations for treatment. In ascertaining the views and preferences of the patient prior to the MDT, it is the recommendation of the RCS that advance care planning documentation can be useful to formalise these views and ensure that documentation is preserved for future decision making, should the patient lose capacity. The MDT should also ensure that the patient’s views and wishes are documented when making recommendations. It is important that the MDT members’ specialist knowledge is used when communicating the treatment options and prognosis to the patient.
The MDT can also be consulted at times where patients lacking capacity require decisions to be made in their best interests. The MDT can not only provide insight into the appropriate treatment options given the patient’s condition, but also advice on what may be in the patient’s best interests given their wishes, preferences and beliefs.
The wider multi-disciplinary team
In many cases, a formal MDT meeting will not be the appropriate forum to discuss a patient’s care and treatment options at the end of life, perhaps because of an emergency presentation or alternative diagnosis not represented by a formal MDT. The surgeon should seek to discuss the patient’s case with relevant professionals to ascertain
- the appropriate treatment options at the end of life available to the patient.
- the patients’ wishes, preferences and beliefs to inform their best interests.
A formal consultation with the palliative care team is particularly useful in this context but the wider team will also include anaesthetists, intensivists, physicians, care of the elderly physicians, other members of the surgical team, specialist nurses, general practitioners and any other healthcare professional that may have spent time with the patient to understand their wishes, preferences and beliefs.
Where patients have made decisions about their care, these decisions should be communicated to all healthcare professionals directly caring for the patient, so that the patient does not receive conflicting information.
Where patients are under the care of an intensive care unit or high dependency unit, surgeons should continue to participate in the care and decisions of patients.
There are likely to be occasions where it is appropriate to handover the care of the patient to other teams more appropriately equipped to care for the patient given their circumstances, for instance, GPs or palliative care services. Surgeons should conduct a thorough verbal or written handover and ensure that all important information required to provide safe, effective and timely care is provided.
Surgeons should communicate with GPs and healthcare professionals in the community, with the patient’s consent, to hand over important information to allow them to give the patient safe, effective and timely care. This should make use of any available electronic handover or sometimes it is appropriate for the surgeon to speak to the GP over the telephone.
Advance care plans, advance statements, ADRTs and the presence of a lasting power of attorney and DNACPR decisions should be handed over, and placed in a prominent position, clearly visible at the front of any case notes.
When patients are discharged, they are sometimes readmitted in an emergency situation. Surgeons should ensure that casenotes offer a precise overview of the decisions that have been made in conjunction with the patient to guide treatment in the case of an emergency.