In the Midst of Life

when patients move between different care settings (hospital, ambulance, care home), and during any out-of-hours period. Failure to communicaterelevant information can lead to inappropriate treatment being given or failure to meet the patient’s needs.
    Mental capacity to decide on resuscitation
    Decisions relating to resuscitation cannot be made by patients who are not mentally capable of understanding their condition, the obvious example being when the patient is unconscious. A patient must be able to understand, retain, and weigh information about themselves, and be able to communicate in some form, in order to make a rational decision about their medical care.
    There are variations in different jurisdictions regarding the legal tests and requirements to determine whether a patient has the mental capacity to make such decisions, but the general medical principles are common to most circumstances. In order to demonstrate effective mental capacity, a person should be able to understand what the medical treatment is, its purpose and nature, and why it is being proposed; as well as comprehending its benefits, risks and the alternatives; they must understand, in broad terms, what will be the consequences of not receiving the proposed treatment; be able to weigh the information in the balance to arrive at a choice; retain the information for long enough to make an effective decision; and make a free choice without external pressure. Different medical treatments may require different levels of mental capacity; for example, the consent process for having a blood sample taken requires a lower degree of weighing and retaining information, compared with the consent process for major, life-threatening cardiac or abdominal surgery. If a patient lacks the mental capacity to make a decision about their care, this should be noted in their medical records, and the clinical reasons for it.
    If a patient lacks adequate mental capacity, then the decision must be made for them in their best interests and urgent medical interventions can be performed, particularly in the case of emergency or life-saving treatments. In the case of serious procedures to be done without consent, it is good medical practice to consider alternative, less invasive treatments; to discuss treatment with all members of the healthcare team; to discussing treatment withthe patient as far as possible; to consult with other healthcare professionals involved with the patient’s care (for example, their general practitioner); to consult relatives, partners and carers; to obtain further opinions from experienced doctors if the patient or their family do not agree with the proposed treatment; and to ensure a record is made of the discussions and any decision taken.
    Again, there are variations on the legal requirements in different jurisdictions. Good medical practice would include consultation with relatives, partners and carers to ascertain what the expected wishes of the patient might be. In England and Wales, the Mental Capacity Act of 2005 has brought a legal obligation for clinicians to take into account the views of anyone named or appointed with power of attorney by the patient for this purpose, their carers, or any deputy appointed by a court. *
    Initial decision to resuscitate
    In an unexpected or out-of-hospital cardiac arrest, when the patient cannot consent to treatment, the assumption has to be that resuscitation should be performed. Death can be verified by any appropriately qualified person, but this is usually done by a doctor, and in the United Kingdom only a doctor who has provided care during the last illness and who has seen the deceased within fourteen days of death or after death can sign a death certificate. If someone is found to have collapsed and died, the emergency services are still obliged to attempt resuscitation as they cannot in general immediately ascertain the underlying condition of the victim. Of course if a person has been dead for some time, for several hours or longer, death will be obvious and resuscitation attempts will not be appropriate.
    Age itself should not be a deciding factor when discussing whether to resuscitate someone who has collapsed, when discussing whether to continue resuscitation attempts, or when discussing whether a patient would wish to be resuscitated or notfrom a cardio-pulmonary arrest. In general, the success of any medical treatment decreases with age, but there is no specific cutoff point concerning