Best interests decision to withdraw life-sustaining treatment — FFICM MCQ

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ModerateEthics and End-of-lifeBest interests decision to withdraw life-sustaining treatmentFFICM

A 79-year-old man has severe hypoxic brain injury after cardiac arrest. Two consultants agree that ongoing invasive ventilation cannot achieve recovery to a state he would value. He lacks capacity. His daughter says he previously stated he would not want prolonged life support after devastating brain injury, but there is no written advance decision. What is the most appropriate management?

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Correct answer: B — Hold a best interests discussion incorporating his values and family input

The correct answer is B, hold a best interests discussion incorporating his values and family input. Under the Mental Capacity Act 2005 (section 4), once two treating clinicians agree an incapacitated patient has no prospect of recovering to a state he would value, the decision on continuing or withdrawing invasive ventilation must be made in his best interests, and this requires consulting those close to him, including his daughter, about his previously expressed wishes, values and beliefs. The daughter's account of his prior verbal statement is relevant evidence of his wishes even though it does not meet the formal criteria for a valid written advance decision to refuse treatment, so it must be weighed within the best interests process rather than dismissed. A formal best interests meeting also allows the clinical team to document reasoning, ensure the least restrictive option is chosen, and involve an IMCA if he has no family, none of which applies here but underlines the required process. Why the other options are wrong: A, ask the family to make the legal decision alone: families have no legal authority to decide under the MCA unless appointed as a health and welfare attorney or deputy; the treating team retains the legal responsibility for best interests decisions. B, continue ventilation because there is no written advance decision: an informal statement that fails the strict criteria for an advance decision to refuse treatment cannot bind the team, but it remains valuable evidence of wishes that must feed into best interests, so treatment cannot be continued purely on this technicality. D, withdraw treatment without discussion because prognosis is poor: poor prognosis alone does not justify bypassing the statutory best interests process; failure to consult family or document reasoning is a breach of the MCA and GMC guidance. E, seek police approval before changing treatment: withdrawing life-sustaining treatment in a patient's best interests is a clinical and legal decision under the MCA, not a police matter; police involvement is irrelevant absent any criminal concern. Key point: An informal prior statement of wishes cannot function as a formal advance decision but must still be incorporated into a structured Mental Capacity Act best interests discussion with the family before withdrawing or continuing life-sustaining treatment.

Reference: Mental Capacity Act 2005, Section 4 (Best interests), legislation.gov.uk, https://www.legislation.gov.uk/ukpga/2005/9/section/4; GMC Treatment and care towards the end of life: good practice in decision making, gmc-uk.org