The term advance directive (increasingly being replaced by the term advance decision) means a statement explaining what medical treatment the individual would not want in the future, should that individual ‘lack capacity’ as defined by the Mental Capacity Act 2005. The term ‘living will’, whilst helping people to understand the concept, is somewhat misleading in that, unlike a will, it does not deal with money or property. Moreover, it can relate to all future treatment, not just that which may be immediately life-saving. An advance directive is legally binding in England and Wales. Except in the case where the individual decides to refuse life-saving treatment, it does not have to be written down, although most are and a written document is less likely to be challenged.
Whilst the patient has capacity their word overrides anything contained in their advance directive or anything their legal representative may say. If doctors have doubts about the validity of an advance decision they should consult early with their indemnity organisation and they may be able to apply to the Court of Protection to overrule it.
In Scotland and Northern Ireland the situation is somewhat different. Advance decisions are governed by common law rather than legislation. However, providing the decision was made by an adult with capacity and clearly sets out the person’s intentions, it is highly likely that a court would consider it legally binding. The term advance statement is sometimes used. This is an expression of the individual’s desires and may refer to personal values, principles and religious beliefs. It is not legally binding but may act as a guide to a doctor who has to make a decision on behalf of a patient who lacks capacity.
The Advantages of an Advance Directive
An advance directive enables an individual to think about what they would like to happen to them in the event that they lose the capacity to take informed decisions about their care. Examples of such decisions include:
- The use of intravenous fluids and parenteral nutrition.
- The use of cardiopulmonary resuscitation.
- The use of life-saving treatment (whether existing or yet to be developed) in specific illnesses where capacity or consent may be impaired – for example, brain damage, perhaps from stroke, head injury or dementia.
- Specific procedures such as blood transfusion for a Jehovah’s Witness.
Even if a directive is not eventually issued, the topic may motivate the individual to discuss future arrangements with their doctor, family and friends.
An advance directive is legally binding in the sense that a doctor, who gave a patient life-saving treatment against their wishes expressed in a directive, faces legal action. However, as the use of advance directives becomes more commonplace, controversies are bound to arise (eg the rights of pregnant terminally ill women) and the legal issues continue to be the subject of debate.
Limitations of an Advance Directive
An Advance Directive Cannot be Used to:
- Ask for specific medical treatment.
- Request something that is illegal (eg assisted suicide).
- Choose someone to make decisions for you, unless that person is given ‘lasting power of attorney’.
- Refuse treatment for a mental health condition (doctors are empowered to treat such conditions under Part 4 of the Mental Health Act).
A Doctor may Decide not Follow an Advance Directive if:
- The individual makes changes which invalidate the directive (eg a change to a religion which prohibits the refusal of treatment).
- There have been advances in treatment which may have affected the initial treatment (unless the individual specified in the directive that such advances would be declined).
- There is ambiguity in the wording of the directive (eg the wording is not relevant to the current medical condition).
A Directive May be Invalid:
- If it is not signed.
- If there is reason to doubt authenticity (for example, if it was not witnessed).
- If it is felt that there was duress.
- if there is doubt as to the person’s state of mind (at the time of signing).
Management of an Advance Directive
For a directive to be enforced, it is first necessary that the clinical team be aware that such a provision exists. It could be recorded in the individual’s computerised or manual notes and a form for the purpose is available from the National End of Life Care Programme website. Just as a will has an executor, so a directive may have a healthcare proxy. This person may also have ‘lasting power of attorney’. Such a provision is common when a person is no longer competent to manage his or her own financial affairs. The role of the proxy is to see that the wishes of the individual are carried out. He or she does not have the power to make decisions. The wishes of the patient may not be overruled by relatives.
An advance directive does not have to be drawn up by a solicitor but neither does a will. However, in both cases, the involvement of such a professional should substantially reduce the chance of an oversight that would result in failure of the will to be observed. A will usually has to be signed by the author and co-signed by two independent witnesses who are not beneficiaries of the will. It is sometimes said that only one witness is required for an advance directive but to replicate a will, two may be safer and they should be people who do not stand to benefit from the estate.
An advance directive can be rescinded or updated at any time but, at the time that it is implemented, the individual is in no position to offer an opinion. If the contents are changed, all old wills should be destroyed.
Drawing up a Directive
Before such a document is produced, it is important for the individual to discuss it with their family. The following checklist may help:
Matters to Consider When Planning an Advance Directive Opinion about the Following Situations
- Would prefer to die
- Would probably prefer to die
- Uncertain either way
- Would probably prefer to live
- Eager to stay alive
- Permanently paralysed but able to relate to others
- Totally dependent on others. Needs to be fed
- Aware but unable to communicate
- Confused and very poor memory
- Constant uncontrolled pain
- Brain damage. In coma. If regained consciousness, markedly impaired.
- Terminal illness, not necessary cancer.
After detailed consideration of the implications, a directive may be drawn up as, for example, those outlined below:
I, (name) of (address) wish the following to be considered in the event of my incapacity to give or withhold consent for medical intervention. If ever I am unable to communicate and have an irreversible condition and I am expected to die in a matter of days or weeks, or if I am in a coma and not expected to regain consciousness or if I have brain damage of disease that makes me unlikely ever to recognise or relate to people then I want treatment only to provide comfort and relieve distress, even if this may shorten my life.
I do not want treatment that can only prolong dying.I consent to any acts or omissions undertaken in accordance with my wishes and I am grateful to those who respect my free choice. I reserve the right to revoke or vary these conditions but otherwise they remain in force.If I am certified brain dead, should any of my organs be of value to others, I give consent to their removal for the purpose of transplantation.
State where copies may be lodged. The person must sign and date the document. Beneath this may be two signatories, also with dates below a statement to the effect that the above signed in their presence and was, to the best of their knowledge under no duress and of sound mind. They also believe that they will not benefit from the estate.
Who Should Make an Advance Directive?
Think very careully about the content of such a directive before committing yourself.
Discuss it with those close to you and try to cover all eventualities.
It is a valid legal document that cannot be overruled by family.
It is not possible to request illegal action such as euthanasia.
It is not possible to request interventions that the medical team regard as excessive and inappropriate.
It can be changed or revoked at any time if you are competent to do so.
It must be signed, dated and witnessed.
It is not essential to make it via a solicitor but there may be some safeguards in doing so.
Doctors and family should know that such an advance decision exists and where it is lodged.
Make sure that you also have an up-to-date ordinary will. About a third of people die intestate.
Your Data Matters to the NHS
Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. The NHS is committed to keeping patient information safe and always being clear about how it is used.
How Your Data is Used
Information about your individual care such as treatment and diagnoses is collected about you whenever you use health and care services. It is also used to help us and other organisations for research and planning such as research into new treatments, deciding where to put GP clinics and planning for the number of doctors and nurses in your local hospital. It is only used in this way when there is a clear legal basis to use the information to help improve health and care for you, your family and future generations. Wherever possible we try to use data that does not identify you, but sometimes it is necessary to use your confidential patient information.
You Have a Choice
You do not need to do anything if you are happy about how your information is used. If you do not want your confidential patient information to be used for research and planning, you can choose to opt out securely online or through a telephone service. You can change your mind about your choice at any time.
Will Choosing this Opt-out Affect Your Care and Treatment
No, choosing to opt out will not affect how information is used to support your care and treatment. You will still be invited for screening services, such as screenings for bowel cancer.
What do You Need to do
If you are happy for your confidential patient information to be used for research and planning, you do not need to do anything. To find out more about the benefits of data sharing, how data is protected, or to make/change your opt-out choice visit www.nhs.uk/your-nhs-data-matters. For a copy of patient leaflet check ‘Our Documents’ page.
We are Joining up Your Health and Care Records to Improve the Local Services you Receive
What Does this Mean for You
Being able to see your health and social care records at any time and in different places means health and care professionals can make quicker and safer decisions about your care. We all use a wide range of health and care services in our lives, whether it’s a visit to see your GP, a hospital appointment or receiving a visit from a social worker. We don’t receive our all of our care in one place or from a single organisation. We may see our GP locally, but go to a hospital in another borough. If we need emergency care, we may be taken to the most appropriate accident and emergency unit, which may be some distance from where we live.
When this happens, each organisation keeps a record of the care we receive; in the past, these records were on paper, but now this is usually an electronic record held separately by each organisation. We are one of a number of GP practices, who are part of a scheme to join up the electronic health and care records of all adults and children in north central London.
Health and care professionals have shared information on paper for many years – we now plan to do this using digital technology. Joining up records in five boroughs (Barnet, Camden, Enfield, Haringey and Islington) is a building block for future plans to join up records across the whole of London but until this happens, your joined-up record will cover these five boroughs.
Most of your current health and care information, such as medication and allergy history, the summary of your care from past hospital stays and future appointments will be included. This will be your recent history as health and care services have not always recorded this information on electronic systems. Sensitive information such as sexual health, HIV status, fertility treatment records, domestic violence and criminal records will not be included.
Over time, it will also include information from other organisations that provide NHS and local authority social care services. (We do not currently plan to include children’s social care records). If you don’t want to be part of the joined-up record, you can opt out now, or at any point in the future. More information and a detailed privacy notice can be found at: www.northlondonpartners.org.uk/joined-up-care-record.
Data Policy and Data Protection Policy
Publication of GP earnings
NHS England require that the net earnings of doctors engaged in the practice is publicised, and the required disclosure is shown below. However it should be noted that the prescribed method for calculating earnings is potentially misleading because it takes no account of how much time doctors spend working in the practice, and should not be used to form any judgement about GP earnings, nor to make any comparison with any other practice.
All GP practices are required to declare the mean earnings (e.g. average pay) for GPs working to deliver NHS services to patients at each practice. The average pay for GPs working in The Speedwell Practice in the last financial year was £73,199 before tax and National Insurance.This is for 2 full time GPs and 5 part time GPs who worked in the practice for more than six months.
Safeguarding Children and Adults
What can I do if I Suspect a Child is Being Abused
As a concerned member of the public, your referral will be treated in the strictest confidence. If you suspect for any reason, that a child is not being treated correctly, please contact the following numbers:
- The Police: 999
- Children’s Services (including out of hours): 0300 123 4043
- The Child Abuse Investigation Unit: 0845 33 00 222
If You Have Concerns That a Vulnerable Adult is Being Abused
- Call Adult Care Services (including out of hours): 0300 123 4042
- If there is a danger to life, a risk of injury or a crime is taking place, call the Police by dialing 999
- If the vulnerable adult is living in a registered care home or receiving domiciliary (home) care services, you can contact the Care Quality Commission (CQC) on 03000 616 161
Let a public service professional, such as a social worker, community nurse, GP, probation officer or district nurse know your concerns. They have responsibilities under the county’s adult protection procedure and can advise you about what to do next.
If you think you are being abused, call Barnet Domestic Violence service as soon as possible: 0208 733 4113 or email on firstname.lastname@example.org
The Practice takes it very seriously if a member of staff or one of the doctors or nursing team is treated in an abusive or violent way.
The Practice supports the government’s ‘Zero Tolerance’ campaign for Health Service Staff. This states that GPs and their staff have a right to care for others without fear of being attacked or abused. To successfully provide these services a mutual respect between all the staff and patients has to be in place. All our staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances. They would respectfully remind patients that very often staff could be confronted with a multitude of varying and sometimes difficult tasks and situations, all at the same time. The staff understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.
However, aggressive behaviour, be it violent or abusive, will not be tolerated and may result in you being removed from the Practice list and, in extreme cases, the Police being contacted. In order for the practice to maintain good relations with their patients the practice would like to ask all its patients to read and take note of the occasional types of behaviour that would be found unacceptable:
- Using bad language or swearing at practice staff
- Any physical violence towards any member of the Primary Health Care Team or other patients, such as pushing or shoving
- Verbal abuse towards the staff in any form including verbally insulting the staff
- Racial abuse and sexual harassment will not be tolerated within this practice
- Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be met wherever possible and explanations given when they cannot
- Causing damage/stealing from the Practice’s premises, staff or patients
- Obtaining drugs and/or medical services fraudulently
We ask you to treat your GPs and their staff courteously at all times.
Removal From the Practice List
A good patient-doctor relationship, based on mutual respect and trust, is the cornerstone of good patient care. The removal of patients from our list is an exceptional and rare event and is a last resort in an impaired patient-practice relationship. When trust has irretrievably broken down, it is in the patient’s interest, just as much as that of the practice, that they should find a new practice. An exception to this is on immediate removal on the grounds of violence e.g. when the Police are involved.
Removing Other Members of the Household
In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family. This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members could put doctors or their staff at risk.