Competence and capacity at the end of life: uneasy paternalism

Brian H Le and Michael D Chapman
Med J Aust 2011; 195 (8): . || doi: 10.5694/mja11.10590
Published online: 17 October 2011

When a patient’s wishes conflict with “best practice”

The question of whether a person has the capacity to make decisions for him- or herself is one that has increasing relevance throughout clinical practice. It is especially relevant in palliative medicine, where practitioners often pride themselves on offering patient choice, particularly when it comes to selecting a venue for receiving care. Patients seen by palliative care services frequently have impaired cognition, often due to delirium.1 Such cognitive impairment places patients at risk of not understanding the ramifications of the decisions that they make. This is likely to become an increasing problem, as palliative care services care for an ageing population, with a significant comorbid burden, who are more at risk of diminished capacity due to the prevalence of illnesses such as dementia. The four ethical principles of health care — non-maleficence (doing no harm), beneficence (doing good), respect for autonomy, and justice2 — remain the foundation for ethical clinical practice. However, in the course of our duties, these principles may come into conflict.

  • Department of Palliative Care, Royal Melbourne Hospital, Melbourne, VIC.


Competing interests:

No relevant disclosures.


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