BMJ Support Palliat Care doi:10.1136/bmjspcare-2012-000429
  • Letter

Response to withdrawal of life-sustaining medical devices and advance care planning

  1. Stephen Clark
  1. Freeman Hospital, Newcastle-upon-Tyne, UK
  1. Correspondence to Dr Maria McKenna, Palliative Care Team, Freeman Hospital, Newcastle-upon-Tyne, UK; mariamckennaa{at}

James Beattie1 is correct that effective communication should begin at the earliest opportunity, usually at the first consideration of using a life-sustaining medical device (LSMD). Some patients will want to discuss all possible outcomes including withdrawal of the LSMD. Some patients will go further and choose to make advance statements describing their preferences and wishes, beliefs and values, or choose to make an advance decision refusing specific treatments. However other patients will only wish to consider the current benefit of the device, especially if this is used long term and provides an improved quality of life, such patients may not be ready to make advance decisions or even to openly discuss withdrawal.

Beattie is concerned that we have described advance care planning (ACP) ‘… only in the setting of assessment of capacity relevant to the Mental Capacity Act (MCA)’. However, the NHS End of Life Care Programme guidance on ACP2 makes clear that the outcomes of ACP are locked into the Mental Capacity Act for England and Wales. Because ACP is a voluntary activity this requires an individual to have capacity, whereas making a best interests decision for an individual who lacks capacity, must follow the process required by the MCA—either way the MCA is the required framework. ACP is a voluntary patient activity, not a professional or target-driven activity. Health and social care professionals can certainly enable this process, but only at the patient's pace.

Effective communication should be a continuous dialogue. For patients who retain capacity to decide about LSMD withdrawal, their current wishes must be ascertained since these take precedence over any previous ACP discussions. For those patients who have lost capacity for LSMD withdrawal, any previous ACP outcomes are central to the decision to be made. Therefore for all patients undergoing LSMD withdrawal, the algorithm will guide clinicians through the required decision-making process.


  • Collaborators National End of Life Care Programme.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Received 4 December 2012.
  • Revision received 4 December 2012.
  • Accepted 4 December 2012.
  • Published Online First 3 January 2013


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