There's an old aphorism in medicine sometimes attributed to Hippocrates: 'c'ure sometimes, treat often, comfort always'. This reminds us to think about goals of care. The end of life is a time when it is important to think ethically and communicate effectively about these goals.
Recognition that a patient is entering the end of life is the first step is determining the goals of care. We are often too slow to see the signs that death is near, and too slow to think that our interventions need to change in order to reflect this. Just because a patient cannot be cured does not mean they should not be treated or comforted.
Good palliative care at the end of life can make the difference between an agonising and emotionally traumatic death or one in comfort, quiet and relative dignity. Good clinical medicine and good ethical reasoning are needed to make sure this happens.
The GMC lists key principles which should control decision-making at the end of life.
Equalities and human rights.
Those at the end of life are owed the same quality of care as all patients, including with regard to dignity and confidentiality.
Presumption in favour of prolonging life.
Any decision about potentially life-prolonging treatment should not be motivated by a desire to bring about a patient's death. There is also a general presumption to take all reasonable steps which can prolong life, though, depending on patient's wishes and doctors' clinical judgement, it may be considered appropriate to refrain from providing or withdraw a potentially life-prolonging intervention.
Presumption of capacity.
The usual assumption that all adults have capacity until it has been shown they lack it applies to patients at the end of life.
Maximising capacity to make decisions.
Capacity should be assessed for each relevant decision, and steps should be taken to support patients in doing so.
Overall benefit.
If a patient lacks capacity, a decision in their overall benefit should be made.
A decision-making model for patients with capacity