The FHJ debate: Failure to produce anticipatory care plans should be a never event

This debate article examines whether a patient dying without an anticipatory care plan (ACP) or treatment escalation plan (TEP) should be considered a ‘never event’. Writing in favour of the motion, an emergency medicine consultant argues that such omissions represent preventable harm – not born of negligence, but of system failure and cultural reluctance to plan for dying. Drawing on a 2018 BMJ Open study showing a three-fold increase in harms among patients without a TEP, he contends that anticipatory planning safeguards patients from non-beneficial interventions, reduces moral distress for staff, and restores dignity at life’s end. A palliative medicine consultant, writing against the motion, challenges the framing of care planning as a universal requirement, warning that autonomy must include the right not to engage. He argues that making ACPs a ‘never event’ risks replacing one form of paternalism with another, and that dying is often too complex and unpredictable to be captured by documentation alone. In his rebuttal, the emergency medicine doctor acknowledges these ethical concerns but counters that the duty lies not in compelling discussion, but in ensuring that every patient is offered the opportunity to plan ahead. He distinguishes system omission from patient refusal, arguing that planning enables autonomy rather than restricts it. The palliative physician’s closing response warns that the good intention to protect patients must never become coercion. Together, the debate explores the boundary between autonomy and safety, raising essential questions about how medicine can prevent avoidable harm while honouring individual choice at the end of life.