Up and down the land, clipboard operatives guided by local PCTs are stomping through care home lounges, offering, as is the way these days, the Gilberts and Biddies all manner of advice and assessments. Those who are found to have mental capacity are read their rights, including the right to refuse treatment; and, if they are so minded, offered a DIY death warrant, or Advance Decision to Refuse Treatment (ADRT), as they are more formally known.
For some, no doubt, an ADRT will be just the ticket. No more futile and burdensome treatment; and no more gratuitous delays at the departure gate. Dr No has no trouble with such arrangements when they are the right arrangements: they are humane and sensible. Indeed, given certain circumstances, Dr No thinks he might even sign his own ADRT.
So far so good. But what about when they may not be the ‘right arrangements’; or when the ‘certain circumstances’ are not met? What about times when the decision to sign an ADRT is done at such a remove that, in effect, it becomes a case not so much of Anticipatory Care Planning, as of Abstract Care Planning? Could pro-active routine whether-you-wanted-to-think-about-it-or-not ADRT offerings, laudable as at first glance they might appear, turn out, at a later time, to be the wrong ticket to the wrong destination?
Dr No thinks this is possible, indeed for some inevitable. Just as, for example (Dr No appreciates he may have stuck his finger through the analogy envelope this time, but doesn’t think he has), quantum mechanics tries but fails to predict whether Schrödinger’s cat is dead or alive, so, it seems to Dr No, there will be times when no amount of abstract assessment and planning can predict whether Gilbert or Biddie will, when the time comes, and the axe is falling, wish to be treated, or not be treated.
Indeed, we can even push the quantum analogy that little bit further. Schrödinger’s cat remains, according to the calculations, both dead and alive for the duration of the experiment, and it is only a direct observation, at the end of the experiment, that determines – indeed triggers – the collapse of the all possibilities into one dead (or as the case may be, live) certainty.
In the same way, Schrödinger’s Gilbert will waver in a quantum world of undetermined intent – until, that is, the day when the decision must at last be made real.
Now, the trouble with ADRTs is that they pre-empt the real, end of the experiment observation, or, in Gilbert’s case, his real on the day it really matters decision. ADRTs, so to speak, cheat on the experiment of life by peeking too early into the box of fate.
Sometimes, of course, Gilbert will retain capacity and the ability to communicate, and so will on the day it matters be able to override his earlier contrary ADRT. But what if, for whatever reason, Gilbert retains capacity, but cannot easily communicate?
Such things do happen, as we saw in an excellent recent BBC documentary, still available for a few days here, which followed the fate of three seriously brain-injured patients. The family of one, given what they knew, provided what amounted to a verbal advance directive that the patient would not wish to be kept alive as a cabbage. The patient, unknown to us at this stage, had changed his mind. Plugs would have been pulled and traces run flat were it not for a wise counsel of watchful waiting, and, in the fullness of time, the communication by the patient of his wish to remain alive.
That is why Dr No is wary of routine abstract out of context ADRTs. We humans are fickle, and we change our minds, all the more so as our circumstances change. If abstract and out of context ADRTs are done, Dr No thinks they should be dubbed Schrödinger Decisions, the better to remind us that they, like quantum mechanics, can all to easily fail to tell us whether the answer is life or death.