• Concept described by Cicely Saunders.
• Includes physical, psychological, social, and spiritual/existential components.
• Important to address all domains during palliative assessments.
• Legally binding in the UK if:
o Valid (patient had capacity when made, no evidence of coercion).
o Applicable to the current situation.
• May specify refusal of specific treatments (e.g., mechanical ventilation, CPR).
• Cannot demand specific treatments.
• Applies when a patient lacks capacity to decide.
• Decision must consider:
o Patient’s prior expressed wishes (verbal or written).
o Beliefs, values, cultural and religious factors.
o Input from family/friends (but family cannot override valid advance decisions).
• Multidisciplinary team discussion encouraged.
• Legally and ethically considered equivalent in the UK.
• E.g., choosing not to start a ventilator is equivalent to stopping one that is no longer in the patient's best interests.
• Permits administration of high-dose opioids or sedatives for symptom relief even if they may hasten death, provided:
o Intention is to relieve suffering, not to cause death.
o Proportionate dose used.
• Recognised in GMC guidance and legal precedent.
Extra Revision Pearls
• Mental Capacity Act 2005 (England & Wales): governs decision-making when patients lack capacity; five key principles.
• DoLS (Deprivation of Liberty Safeguards): apply to restraining patients in hospital or care settings
— must be least restrictive and in best interests.
• Futile treatment: interventions offering no meaningful benefit can be lawfully withheld or withdrawn.
• Resuscitation discussions: DNACPR forms only cover CPR, do not imply other treatment limitations unless explicitly stated.
• Palliative sedation: used for refractory symptoms at end of life; distinct from euthanasia.
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
