Lack of evidence to show Mr O had agreed to the Trust’s treatment plan
14. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any indication that something has gone wrong.
15. Mrs O has told us that even after attending a local resolution meeting with the Trust, she still felt uncertain about whether her husband had discussed and agreed to the Trust’s decision not to intubate and ventilate him. Although the Trust had reassured her these conversations had taken place, the paper record it gave her contained very little information, other than the DNAR (do not attempt cardiopulmonary resuscitation) form. Mrs O says these were the only records the Trust had given her, as it said the rest were electronic records.
16. In its complaint response dated 19 January 2021, the Trust said the decision to palliate Mr O, meaning to relieve his symptoms only, was taken by the consultant and discussed with Mr O.
17. Relevant guidance relating to decisions about end-of-life plans, is provided by the General Medical Council (GMC). This GMC guidance tells doctors they ‘must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including: their condition, its likely progression and the options for treatment, including associated risks and uncertainties’.
18. We can see, from the electronic records provided by the Trust, that on 10 April the Trust rang Mrs O to update her and to clarify her understanding about Mr O’s condition. It explained that Mr O was requiring a lot of oxygen and he was very unwell. It said he was working hard with his breathing, receiving oxygen via a CPAP mask, and that he may still need ventilating. This is where the patient is mechanically assisted to breathe via a tube inserted into the trachea, under sedation or anaesthetic. The Trust said at that time, however, it did not plan to ventilate Mr O.
19. The electronic records also say that on the morning of 13 April, Mr O had deteriorated over the weekend. He had increasing levels of oxygen support but with no response in the blood oxygen levels. The Trust says two consultants assessed and discussed Mr O’s condition, and both agreed that if Mr O deteriorated with his breathing, he would not benefit from intubation and invasive ventilation. The GMC says doctors must decide what is in the patient’s best interests and are not required to provide treatment they consider to be out of line with this.
20. The records also show that in this case Mr O agreed with the consultants’ decision. One of the consultants then rang Mrs O later that day to explain their decision to her. They told her that if/when her husband deteriorates, despite all the available measures, it would be best to make him comfortable in his final hours. They also explained that if this did happen, although sadly no visiting was allowed at that time, they would ensure someone would remain with Mr O in his final hours. This record notes that Mrs O expressed her hope that they would not let him go in distress if it came to it, but she was content to leave that decision in the Trust’s hands.
21. The records show that Mr O’s breathing became more difficult throughout the day, and this difficulty was discussed with Mr O that evening. Mr O agreed that resuscitation, intubation, and ventilation were not in his best interests, or likely to be successful. He agreed to pre-emptive medications (medicine for relief from pain, anxiety, and agitation). The records say this was discussed with Mrs O shortly after.
22. The records document that later that evening, the consultant was asked to come and see Mr O. It says this was because Mr O had removed his CPAP mask and was asking to keep it off. The consultant came and explained to Mr O that, although it was Mr O’s decision, if he did not put his mask back on, his oxygen levels would fall very quickly, and it was extremely likely that he would pass away as a result. Mr O removed his mask and was given a drink. He said he understood the likely outcome, but he wanted to keep the mask off anyway. The consultant administered diamorphine (pain relief) and said someone would stay with him, which they did.
23. GMC guidance tells doctors they, ‘must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including: their condition, its likely progression and the options for treatment, including associated risks and uncertainties’. This means that if a patient declines a treatment, the clinician needs to make sure the patient understands the potential consequences. There is evidence the Trust did this and these discussions were documented in the records. We can see that Mr O had agreed in advance to the limitations of his treatment. He was also told on the night before he died, what the consequences of removing his mask would be. The records clearly support that Mr O was fully aware of the likely outcome. However, this was a decision he was entitled to make and he chose to make it at the time.
24. Based on the information in the Trust’s records, and what Mrs O has told us, we have not seen any indication of a failing on the Trust’s part.
25. We thank Mrs O for bringing her complaint to us and understand she just wanted to be sure that her husband was aware and agreeable to the treatment plan, should he deteriorate. We hope our independent view gives her some reassurance about this.