I have a few concerns in regards to refusal of treatment and NFR orders. We need to be familiar with the 2 mechanisms a patient can refuse treatment, under common law position and legislative frameworks - Medical treatment act 1988 and Guardianship and Administration Act 1986. Problem is, I've been unable to go on further with the 2 - particularly both Acts, neither are covered in my text books (Essentials of Law for Health Professionals, Forrester & Griffiths and Health Care & the Law, Wallace). Lecture notes state the Med. Treatment Act is to clarify the law relating to rights of patients to refuse medical treatment, established for clearly indicating a decision to refuse medical treatment. Guardianship & Administration act notes state the act is for appointment of a guardian by a competent person who is able to make decisions regarding treatment, lifestyle and other non-financial matters. Are there any boundaries to refusing medical treatment?

I know NFR order doesn't rule out palliative care and the order can be for medical treatment in general or specifically. But when a patient refuses medical treatment in general restricting one to providing palliative care only - depending on patient circumstances, for example unable to take anything orally, how is a nurse supposed to go about the reasonable provision of medical procedures to relieve pain, suffering, discomfort and reasonable provision of food and water if things like PEG tubes are considered to be medical treatment?

We have a form which is filled out for all NFR patients - it specifies what intervention the patient is to have (CPR, DCR, ICU admission, inotropes, MET calls [medical emergency response for conditions such as RR >36, SBP

If the patient is unable to tolerate oral intake, and has decided against parenteral feeding, we give them the option of subcut or IV fluids. Oftentimes we don't administer fluids at all - depending on the underlying problems, dehydration can be comfortable: patients with oedema or ascites reabsorb the fluid, reducing pain and discomfort. Good mouth care alleviates the unpleasant effects of dehydration. In fact, for patients who are dying and request a drink, chips of ice reduce thirst without risking the patient.

A lot of people find the idea of not administering food and fluids distressing. It's natural in end-stage disease to have diminished or absent appetite, and reduced thirst. or patients who are dying, food and fluids prolong life without alleviating the underlying issues; in some conditions food and fluid can actually increase discomfort, by causing nausea, vomiting, aspiration risk and distress.

It can be distressing to watch someone die and not be able to help - the thing to remember is that it's not about us, it's about the patient; forcing unwanted therapy on to someone who's already going through more than enough, is unfair.

Hope this helps :)

thanks. i was getting the requirements, what makes each a valid order and general information about each mixed up, but this helps. was not aware of nfr forms until some of the div 2 nurses mentioned this in our last tutorial. our lecturer did not know nfr forms existed either - which is probably why it wasn't on our lecture notes.

mmmm end of life issues - something that we as nurses and doctors will always have issues with. While ever there are issues between identified patient wishes and percieved medical need there will always be potential for ethical debate. A question we need to ask is when we are providing care - why are we doing it - to help the patient or to keep them alive (because there can and definately is a difference at times). The ability to recognise that there is an end of life and supporting patients through a dignified end of life is the best thing that we as health professionals can do (unfortunately the law isn't neccessarily written to support dignified life & death, rather it is often interpreted to support living life only)

Cheers

Peter