Advance directives are statements that outline a refusal of treatment in specific circumstances, where they can no longer make decisions over their health, e.g. when they are unconscious or incapacitated. It is made by an adult who has full capacity. The treatment to be refused must also be specified, although it cannot determine which treatments are given.

When is advanced directive applied?

The Mental Capacity Act (2005) outlines guidelines for writing an advance directive. An AD must be followed if it is applicable to the specific circumstances, and is valid, even if a doctor believes that it is not in the best interests of the patient to follow it.

An AD refusing life-saving treatment must be made in writing and have a witness.

Is the document that Ryan is carrying an effective AD to refuse treatment of blood products?

In order to follow to the Mental Capacity Act (2005), the Hospital Information Services for Jehovah's witnesses published an "Advanced Directive to Refuse Specified Medical Treatment." This states that people can refuse transfusions of blood or primary blood components e.g. platelets and red and white blood cells. But, this does not include the use of non-body fluids to increase volume, and the process of blood salvaging.

So Ryan's AD specifies that he does not want a blood transfusion, and it is witnessed and in writing, although prior consultation/discussion with a healthcare professional about the AD is not necessary. It is applicable to this circumstance. But, the doctors were within their rights to act in what they thought were the best interests of the patient, and use blood salvaging.

Treating a patient in an emergency situation

If no AD is found on a patient, the patient must be treated in what the doctor considers to be their best interests.

Treatment should not be delayed in an attempt to clarify if an AD exists (e.g. by waiting for, or contacting the family). If the healthcare team treat a patient, unaware that an AD exists, then they are protected from liability.

In Scotland the Proxy Consent and Adults with Incapacity Act (Scotland) 2000 , makes it legal to give or withhold consent on behalf of other adults in Scotland.

• Is the doctor acting in the Ryan's best interests (autonomy) following the AD, or should they do everything they can to save his life in an emergency situation (beneficence)?
• Can the doctor be sure that the patient had capacity or was not under duress when he signed the AD, and was the patient fully informed and aware of the consequences of AD when they wrote it?
• Is the doctor acting against the patient's wishes and religious beliefs by following the 'Advanced Directive to Refuse Specified Medical Treatment', and treating him with non-body fluids and blood scavenging?

• If the doctors had not found an AD on Ryan, they should have treated him according to what they thought would be in his best interests.
• Because they did find an AD, which specified the circumstances, refusing potentially life-saving treatment, and which was signed (while confirmation was sought from his brother too), they had to follow it even if they don't think it is in the patient's best wishes, as the patient's wishes were made clear. If the doctor did not follow the AD, they are at risk of being accused of battery.
• It is up to the doctor in charge of the patient to decide whether or not an AD is applicable and valid, and hence what treatment is required.
• According to hospital protocols, the updated "Advanced Directive to Refuse Specified Medical Treatment", an individual can refuse transfusions of blood or primary blood components e.g. platelets and red and white blood cells.
• However, this does not include the use of non-body fluids to increase volume, use of volume expanders, and the process of blood salvaging, to try and save their life. Although this is not ideal, it does provide some form of treatment to those refusing blood transfusions.

• Mental Capacity Act 2005
• Advanced Directive to Refuse Specified Medical Treatment - Hospital Information Services