The Overnight Plan That Contradicts the Comfort Plan
Mrs B is 81 and has advanced dementia: she is bedbound, has minimal verbal communication, and has had aspiration pneumonia three times in six months. Five days ago a consultant-led meeting with her daughter, her next of kin, agreed a comfort-focused plan - no artificial nutrition or hydration, no ICU transfer, symptom control only. It is written in the notes and countersigned by the daughter. At 22:00 on a Saturday a covering registrar who has never met Mrs B writes: 'Insert NG tube, 1 L Ensure over 12 hours, IV co-amoxiclav, for full escalation including ICU.' You are six months qualified, on night duty with one healthcare assistant and nine other patients.
1. Explain the professional and ethical problem this creates, and identify what would and would not count as a valid change to Mrs B's plan.
Read the worked answer
The problem There are now two documented, conflicting plans. You cannot implement both, and you cannot silently ignore a written entry either. Whatever you do, you are accountable for your own action - 'the doctor wrote it' is not a defence.
Why the original plan carries weight
- It was made by the consultant with decision-making responsibility, with the person who knows her best, and it is signed and countersigned.
- It reflects her will and preferences, which must be considered even where capacity is impaired (Assisted Decision-Making (Capacity) Act 2015). Capacity is presumed unless shown otherwise, and is decision-specific.
- The plan is clinically coherent: in advanced dementia with recurrent aspiration, an NG tube carries real risk of aspiration, discomfort and possibly prolonging dying without restoring function.
What would be a valid change Only a genuine reassessment: a documented clinical change (e.g. a reversible cause now treatable), discussion with the family, and a decision by the consultant or on-call consultant. A single entry by a doctor who has never met her, with no recorded discussion and no stated clinical rationale, is a query to be resolved - not an automatic revocation.
2. Set out what you will do, in order, over the next hour.
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- Do not insert the NG tube or give the feed. Nothing is lost by an hour's delay; an aspiration event cannot be undone. Continue comfort care - repositioning, oral care, PRN anticipatory medicines for pain and distress.
- Re-read the notes and confirm the comfort plan is the current, consultant-level decision and check for any advance healthcare directive or DNACPR form.
- Contact the registrar directly and present the facts neutrally: 'Mrs B has a documented comfort-focused plan agreed with her daughter five days ago. Your entry tonight changes that. Can you tell me what has changed clinically, and can you review her at the bedside?'
- Escalate if unresolved: the consultant on call for the medical team, then the nursing site manager/ADON, and palliative care if available. Keep going up until someone with authority resolves the conflict.
- Stay with the patient in the sense of keeping her comfortable and safe; delegate obs and the other nine patients to the HCA only within their competence.
- Document contemporaneously: time, who you spoke to, what was said, what you did and did not do, and why.
3. The registrar says: 'I've written it, you have to do it.' How do you respond, and what do you document?
Read the worked answer
Response Stay calm and non-confrontational but clear: 'I'm not refusing to care for her - I'm not comfortable giving artificial feeding until we know which plan is current. I need you to review her with me, or I'll need to ask the consultant on call.'
Avoid:
- 'I'll get in trouble' (frames it as your problem, not hers).
- Silently complying to keep the peace.
- Amending or scoring out his entry yourself.
- Writing 'patient refused' when the patient did not refuse.
Documentation should record:
- The exact conflict (comfort plan dated X vs entry dated Y).
- Your concern and the clinical reasoning behind it.
- Who you contacted, when, and their response.
- That you withheld the intervention pending review, and that comfort measures continued.
- The outcome and who took over responsibility.
If harm or near-miss occurred, complete an incident report through clinical governance. Also flag it for the day team and the ward manager - a pattern of overnight plans overriding agreed ceilings of care is a systems issue, not a one-off.