Conflict and confusion often surround the application of religious beliefs to end of life decisions. Keeping a clear and open dialogue with patients and their family and friends is vital to surmounting the challenge of keeping everybody happy, write Becky Fitzpatrick, partner at Hill Dickinson LLP and Dr Timothy Strang, consultant anaesthetist at University Hospital of South Manchester.

The Department of Health’s End of Life Care Strategy in July 2008 was followed by detailed GMC guidance in July 2010. These provide a clear framework for clinicians to work within when making decisions about end of life care. The guidance highlights the need for maximum patient input, be this directly or through powers of attorney, friends or family.

Under Article 9 of the European Convention of Human Rights, a patient’s religion may be an important consideration when making treatment decisions. Religious integrity may be as, or more important to some patients as their physical condition, while aggressive life sustaining treatments may be favoured by those who perceive a decision to terminate such care as a violation of the sanctity of life.

Research confirms some patients use religion to cope with illness and inform decisions whether to accept, continue or cease life-preserving treatment. It is therefore important to be aware of the values by which the patient has lived their life, when ensuring dignity during their last days.

Yet the interpretive nature of religion and its application to end of life decisions, whether communicated by a competent patient or taken by a clinician subject to the views of family and other relevant individuals, provides fertile ground for conflict and confusion. These situations must be managed with sensitivity by staff at the forefront of providing care.

The first step is identifying those patients who are facing the end of life and initiating discussion in a way that explores their religious beliefs. The clinician’s task becomes more complicated where friends, family and others are to be consulted. Conflict may arise within a group purporting to follow the same religion. In such situations, the clinician may seek input from a more suitably informed medic or external religious authority.

Independent mental capacity advocates with suitable specialist knowledge clearly also have a role to play in circumstances where neither friends nor family are available to assist.

Key considerations will include initiating open, honest and clear discussion with the patient regarding treatment as early as possible and establishing the religious views and other values the patient identifies as informing their healthcare choices.

Such discussions should be carefully recorded by drawing up a clear care plan, which should be regularly reviewed and available for out of hours and emergency healthcare professionals. Staff should be aware of the patient’s preferences and advance decisions should be examined.

When considering care for the patient after death, a clear written record of any explicit provisions made by the patient in earlier discussion should be made. A staff member with appropriate seniority should also discuss this matter with the family to ensure the relevant cultural and religious needs are respected.

Case Study

University Hospital of South Manchester Foundation Trust

  • P suffered a cardiac arrest and was ventilated;
  • P’s brain stem demonstrated minimal functioning. Neurologists confirmed catastrophic anoxic brain injury and that in time P was likely to be diagnosed PVS;
  • P was Jewish by birth but had a secular marriage. P was in a new relationship and had been starting to explore revisiting the Jewish faith;
  • The secular side of the family did not want to prolong treatment, but the Jewish side wanted to treat P forever;
  • The Rabbi involved was against cessation of treatment;
  • A best interest meeting was convened, involving the family and Rabbi. The meeting concluded it was in P’s best interests to cease treatment. The family were satisfied with this decision but required support in how their community was to be informed;
  • Cessation of care was planned to take place on Saturday but due to this being the Jewish Sabbath, it took place on the Sunday instead. The secular family visited, followed by the asecular family, to look after the body according to the customs of their faith.

Practical Tips

  • Take responsibility for difficult decisions and conversations
  • Ensure adequate support is provided by clinical colleagues
  • Seek legal advice where appropriate
  • Encourage those with strong religious beliefs to consider an advance decision
  • Involve the local chaplaincy, which may have connections with relevant community organisations
  • Check the patient’s decisions are their own (and not a result of coercion)
  • Ask those representing the religious views of the patient to explain their views and what action they expect you to take; some may expect you to automatically know this. Such a discussion can remove any ambiguity and frustration
  • A Court Order can resolve conflict by concluding medical treatment and taking responsibility for the decision away from the family
  • Remember religion plays a role in the timing of treatment and the type of care provided after the death of a patient.

Publications

For patient views, see www.patientopinion.org.uk