Basic care, pain relief, and advance healthcare directives in Ireland

The Assisted Decision-Making (Capacity) Act 2015 (ADMCA) provides a legislative basis for advance healthcare directives (AHDs) in Ireland. AHDs offer important benefits to patients, including preserving autonomy and allowing for greater control over end-of-life care. However, they can also create difficult ethical dilemmas, especially in respect of AHDs refusing basic care, pain relief and palliative symptom management. We use a hypothetical case study to interrogate how such directives should be addressed under the ADMCA and identify some uncertainties and ambiguities within the ADMCA concerning refusal of palliative care and pain relief. We argue that these dilemmas can only be properly understood by looking at the entirety of the legislative framework and not just at definitional issues around basic care. Although many ambiguities can be addressed within the framework of the ADMCA, including through consultation with the directive-maker's decision making representative, if there is one, or family members, this will not always be the case and so we have also advanced an argument that, when palliative care is refused, even if the healthcare professionals conclude that the AHD is valid and applicable, there is still a case for referral of the matter to court.