By Dr Olawumi Ogunrinde, GPST2, and Dr Ramesh Thulavavenkateswaran, Specialist Grade Doctor in Palliative Medicine. This joint reflection from a GP specialty trainee and his clinical supervisor arose from a community palliative care placement caring for patients who lacked mental capacity. Bringing both perspectives together highlights how ethical decision-making is learned, practised and refined in everyday clinical care.
These situations are rarely straightforward: they demand careful clinical assessment, multidisciplinary collaboration, honest communication with families, and a firm commitment to the ethical principles of person-centred care. Two encounters stood out, each showing how the four principles of biomedical ethics — beneficence, non-maleficence, autonomy and justice [1] — must be balanced to keep a patient’s best interests at the centre. We describe them below, and then each of us reflects.
Individualising Diabetes Management in Advanced Dementia
The first patient was a lady with advanced vascular dementia and Type 1 diabetes mellitus. Her husband, who held a valid Health and Welfare Lasting Power of Attorney (LPA), felt that frequent capillary blood glucose monitoring was causing her distress without meaningful benefit.
Rather than change her treatment unilaterally, the palliative care team discussed it with her GP, her diabetes specialist nurses and her husband. Together, they agreed to reduce monitoring, modestly decrease her insulin dose and accept a wider target range of 6–15 mmol/L.
This mirrors national end-of-life diabetes guidance, which advises that in the last phase of life the aim of glucose control shifts from tight targets to simply avoiding symptomatic hypoglycaemia and hyperglycaemia [2].
For a frail patient near the end of life, sparing her the danger and distress of hypoglycaemia matters more than achieving a tidy figure on the glucose meter. The decision honoured her husband’s role as attorney (autonomy), removed a burdensome procedure (beneficence and non-maleficence), and ensured her advanced dementia did not lead to less thorough or lower-quality care than any other patient would receive (justice).
Behavioural and Psychological Symptoms in Dementia
The second patient was an elderly man with suspected but undiagnosed dementia living in a care home. Staff described increasing nocturnal wandering, restlessness, disinhibition and undressing at night — distressing for him and for those caring for him.
As with any acute behavioural change, the first step was to exclude reversible causes; assessment with his GP and community nursing team looked for infection, metabolic disturbance, medication effects, pain, constipation and urinary retention, and found none.
Only then, after discussion with his son, who held LPA, and careful consideration of the risks and benefits, was a low-dose antipsychotic started, alongside continued non-pharmacological measures and with a clear plan for regular review and withdrawal if the behaviours settled. This follows NICE guidance, which reserves antipsychotics in dementia for people at risk of harm or in severe distress, and only as an adjunct to non-drug approaches [3].
The reasoning mattered. His distress and threatened dignity supported treatment (beneficence), but antipsychotics carry real risks in older people with dementia — stroke, falls, sedation and increased mortality — so they were used cautiously and never as a default (non-maleficence), with his attorney consulted throughout (autonomy) and equitable specialist assessment ensured despite his cognitive impairment (justice).
The Mental Capacity Act in Practice
Both encounters show the Mental Capacity Act 2005 at work. Capacity is presumed unless shown otherwise; people are supported to decide for themselves wherever possible; decisions made for those who lack capacity must be in their best interests; and the least restrictive option is chosen.
A best-interests decision is not simply the clinician’s view of what is best; it considers the person’s known wishes, feelings, values and beliefs, as well as the views of those close to them. As the GMC makes clear, this same framework applies at the end of life as in any other area of care, and doctors must work with those who hold legal authority to decide on a patient’s behalf [5,6].
Involving families and attorneys holding LPA is therefore not merely good communication; it is a legal and ethical component of good care.
A Trainee’s Reflection:Dr Olawumi Ogunrinde
The most valuable lesson of this placement has been that ethical decision-making is rarely a choice between right and wrong. More often, it means balancing competing priorities while keeping the patient’s values, comfort and dignity at the centre.
Working alongside my supervisor showed me the importance of thoughtful clinical leadership, multidisciplinary teamwork and compassionate communication with families.
Seeing how a shared decision could lift a burden from a patient without compromising her safety reframed my understanding of what “doing something” for a patient can mean. Good palliative care, I have come to see, extends well beyond symptom control — it is equally about sound ethical judgement and treating the whole person, and it is a mindset I will carry back into general practice.
A Supervisor’s Reflection:Dr Ramesh Thulavavenkateswaran
Encounters like these are, to me, some of the richest teaching opportunities that palliative medicine offers a trainee. The clinical decisions — loosening a glucose target or starting a low-dose antipsychotic — are not in themselves complex. Their value lies in what surrounds them: the disciplined exclusion of reversible causes, the involvement of an attorney under the Mental Capacity Act, and the honest weighing of benefit against harm.
Since most people near the end of life are cared for in the community, the confidence to reason ethically and individualise care is exactly what a future GP needs.
My role is less about providing answers than modelling the reasoning before stepping back and showing that these skills belong in general practice just as firmly as they do in the hospice.
Conclusion:
While the clinical details differed, both cases demonstrated the same underlying principle: when patients can no longer make decisions for themselves, good palliative care depends on careful assessment, collaborative working and a commitment to understanding what matters most to the individual. Ethical decision-making is not separate from clinical care—it is a fundamental part of it.
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References
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford: Oxford University Press; 2019.
- Diabetes UK, TREND Diabetes. End of Life Guidance for Diabetes Care. 5th ed. Diabetes UK; 2024.
- National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. NICE guideline NG97. London: NICE; 2018 (updated 2022).
- Mental Capacity Act 2005. London: The Stationery Office; 2005.
- General Medical Council. Treatment and care towards the end of life: good practice in decision making. Manchester: GMC; 2010 (updated 2024).
- General Medical Council. Decision making and consent. Manchester: GMC; 2020.
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