Total pain

•    Concept described by Cicely Saunders.

•    Includes physical, psychological, social, and spiritual/existential components.

•    Important to address all domains during palliative assessments.

Advance directives

•    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.

Best interests

•    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.

Withdrawal vs withholding treatment

•    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.

Doctrine of double effect

•    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•    Futile treatment: interventions offering no meaningful benefit can be lawfully withheld or withdrawn.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.