Guidance on advance care planning

Waterman et al ¹ perform a useful service in drawing attention to the need for psychiatric in-patient units to develop expertise in terminal care. It is a shame that they have not acknowledged the guidance on advance care planning developed by the Royal College of Physicians ² in conjunction with the Alzheimer's Society, the Royal College of Psychiatrists, and other lay and professional groups.

The authors have also misunderstood the status of advanced decisions to refuse treatment made under the Mental Capacity Act 2005. To be valid, an advanced decision must specify a particular treatment which is not to be carried out or continued (section 4 of the Act). It is not possible to make an advance decision to die at home and not go into residential care (although it would not be possible to use the Deprivation of Liberty Safeguards to require a person to stay in hospital to receive treatment that had been refused in advance). It is not possible to require health care professionals to provide a specified treatment. ³

It is best to regard advance care plans as statements of wishes and feelings about what is in the patient's best interests. The Mental Capacity Act places particular emphasis on relevant written statements made by the patient when he/she had capacity (section 6a; see also the Mental Capacity Act Code of Practice, paragraphs 5.40–5.45). There are likely to be times when most psychiatric patients will lose capacity to make some decisions. Ascertaining how patients would like to be treated when they are unable to make decisions for themselves should be part of routine practice with all psychiatric patients.