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Rapid Responses: Rapid Responses published:
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Oh, please!
- Bill Rudersdorf (15 January 2000)
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Dying to live
- Pablo Millares-Martin (15 January 2000)
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A realistic Look to life
- Refaat Guirguis (16 January 2000)
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Re: Dying to live
- Peter Davies (17 January 2000)
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Dying-Learning the lessons of life
- Tyler Meadows (17 January 2000)
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Death: the new(old) business of Y2K
- Anna V Ciardullo (19 January 2000)
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Sharing control in death, find an "amicus mortis"
- James Grogono (20 January 2000)
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Re: Dying to live
- Meenu Grover (20 January 2000)
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Guidelines to improve dying
- Andrew Fowell, Ilora Finlay (21 January 2000)
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The state of dying in Britain today
- Clive Seale (21 January 2000)
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Survey of psycho-social support for dying people
- Susan Elizabeth (24 January 2000)
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A good death
- Mamoun Mobayed (24 January 2000)
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The accomplishment in helping patients to die well
- M Anne Chamberlain (24 January 2000)
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Principles of a good death
- Ann Bowling (29 January 2000)
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A Good Life
- Sheila Barnfather (9 February 2000)
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A Good Death - A Paradox
- Margaret Brown (2 March 2000)
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Don't stop a dying person's drug unnecessarily
- D Nelson (10 May 2000)
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Bill Rudersdorf
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Good words, all. Or most. Could we have a moratorium, for maybe a decade, on the word "apotheosis"? It actually has fecund possibilities in an article on death (if anyone were to know its actual meaning), but I say "toss it". Happy trails, Bill |
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Pablo Millares-Martin, GP Leeds
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A good death [1] seems a very pessimistic editorial to start a journal. Even worse are the initial comment that every BMJ reader will die this century and the final one regarding the painful life which lasts forever. These comments are more appropriate to a doomed to the NHS waiting list patient than to a health professional. Does the author suffer from depression? Does he understand the meaning of Life? One could ask as well Where is Faith in Medicine? Where is Faith in the Future? We are caring nowadays after people who is over 100 years old when the average "natural" life span seems to be about 70 years. The elderly population is growing fast and nobody can predict how long human beings will live in 100 years. The search for immortality surround us [2] not as science fiction but as a remote possibility with advances such as identifying the gene that prevent atherosclerosis [3], so 55% of deaths can be delayed. We are an inexperienced species still trying to survive to the elements. It does not mean we have to accept it, to die in silence. Progress in medicine is extending slowly our lifespan. Death is becoming a rare event, and in consequence people can not respond to it the same way as if it were a common battle. The families with ten children of which only half would survive to adulthood is something of the past. Obviously it is not something you talk about frequently, because there are no frequent deaths to talk about. We need to educate ourselves to manage the dying patient and their relatives and not only for them but for our own sake. This depressing editorial shows no light, but darkness to the issue. It contributes in creating a taboo out of this theme by surrounding it with mystique. There can not be a good death for as long as it means the end of a good life. But death is not a failure of the doctor or the system, it is simply a manifestation of our own fragility, a reminder we have to care about our lives as they are unique and precious. [1] Smith R "A good death" Editorial. BMJ (2000) 320:129-30. [2] Abbasi K "Future Medicine" Reviews BMJ (2000) 320:194. [3] Watson R "Scientists identify gene to prevent atherosclerosis" News BMJ (2000) 320:140. |
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Refaat Guirguis, Consultant obstetrician and gynaecologist Mersey Community Hospital,Latrobe,Tas,Australia
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The main objectives of medicine have always been the correction of anatomy,restoration of function and pain relief.Prolongation of life, as such, has not been an aim in itself but rather the product of medical progress. ----- As a result of that progress, the concept of death in life has been minimized and or lost totally as part of human search for immortality. -----Humans are not designed to live forever(genesis 1:22)and therefore their death is a natural event in their existance. ----- The conflict between modern medicine and the natural decline in the human body is the failure of acceptance that natural decay is but part of a normal process that need not be corrected but accepted as we do accept the phase of growth and development of a human emberyo for example. ---- This veiw is clearly based on a religious and cultural background.This is rather difficult to talk about in modern medicine where evidence is required.but the evidence is their no one has lived forever. ---- I would like to add my voice to the auther, lets put things in their proper prespective and think of dying as a natural event rather than a disease to treat. |
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Peter Davies, General Practitioner Alison Lea Medical Centre
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I think Dr Millares-Martin has got his views back to front. The search for immortality is a sign of our fear of death and our unwillingness to accept the inevitability of our own death. Whatever our fears we will all have to face death, whether we are ready for it or not. This fact is neither threatening nor fearful unless we allow ourselves to perceive it as such. If we do perceive death as a threat, something awful to be feared, then it is our perceptions which are wrong, not the fact of death. In our current society death is perceived as something fearful. Doctors as major players in our modern world have a part to play in shaping views on death. Some doctors share the general fears of death and see medical progress only in terms of prolonging life and preventing death. Although these may be laudable objectives the major paradigm shift that must occur is that we as individual doctors and as part of society must lose the fear of death, and stop seeing death as a failure. Even if we do find a cure for cancer another disease will appear to detatch us from life. I believe that one purpose of earthly life is to prepare us for the next life. At the appropriate time we must be willing to give up our life. Even if we are unwilling our life will leave us. I believe a good death is one where we can accept the reality with good grace. To achieve this is easier said than done but it is a goal that we as people, and as healers for our patients, should be working for. Acceptance of death would be a great advance in the practice of medicine. Yours sincerely, Peter Davies |
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Tyler Meadows, Hospice Hospice Volunteer
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I'm very much in support of death education. Our society teaches people how to be born, rarely does society teach you how to die, or live for that matter. When one denies their ultimate death, they also deny their exsistence. One of my favorite questions to ask a person who is on the verge of death is "How did you live your life before your body became ill, and what are your thoughts on life now? The responce is usually very similliar. Nothing really matters accept "love." Whether you are rich or poor, you are going to die. Money means nothing in the end. What counts is the lessons learned about treating your fellow humans; how to be kind and more giving. If you were to live each day as if tommorrow was your last, how would you live? Tyler M. |
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Anna V Ciardullo, Consultant Centre for the Evaluation of Health Care Effectiveness - Modena - Italy
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A good death is the result of two concurrent moments: Nothing more we have to say or to do. Please, avoid making death the new (old) business of the millennium.
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James Grogono
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Editor--May I offer one further ingredient to "A good death"(1,) that is an amicus mortis a "friend at death". Most items on your list of "principles" use the word "control" or imply it. Yet the very process of death involves losing control. Control of strong drugs is especially difficult for the one who is dying. An "amicus mortis" makes it easy. The following was written within days of my wife's death from cancer four years ago, and was read at her funeral. "Towards the end I was given the privilege of care. I don't want
to belittle the role of the care team. Nonetheless I was the lucky one in
charge, especially at night, and my task was an easy one, aided by small
doses of morphine towards the end.
The role of "amicus mortis" is a most life enhancing one, and there should thus be no shortage of supply. I had a further small dose of it last month when my father died. My older brother, enviably in full retirement, played the main role. He closed down his home in the Carolinas for a couple of months for the purpose. He endorses this view. The chosen person must have time and love and prescribing power. Perhaps it is an unfair advantage to have doctor-husband or doctor-sons available, but prescribing power can easily be delegated, and the other attributes are just as important. I fully agree with your view that there is nothing macabre or morbid about thinking of death and planning your funeral throughout life, but I do suggest that it is equally important to choose and cultivate your amicus mortis, and see to it that he doesn't die first. James Grogono
Smith R (editorial) A good death. BMJ 2000;320:129-30 |
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Meenu Grover, Medical Information Manager Ranbaxy Labs Limited, India
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Wishing for a happy ending to a good drama is not pessimism. Certainly, optimism is not about making difficult subjects taboo and pretending they do not exist; its about discussing what could be done. I feel that this editorial is, in fact, the most optimistic piece I have read in years. The Bhagavad-gita, universally renowned as the jewel of India's spiritual wisdom and definitive guide to the science of self realization mentions, " As the embodied soul continuously passes, in this body, from boyhood to youth to old age, the soul similarly passes through death. A self-realized soul is not bewildered by such a change." Of course, we are all dying to live - and in style. But that does not call for bewilderment at the mention of death- that too in style. |
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Andrew Fowell, Macmillan Consultant and Professor (Marie Curie) of Palliative Medicine Ysbyty Gwynedd and Velindre NHS Trust, Ilora Finlay
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Editor, People always have and always will die (1). Palliative care has now come out of hospices and is accepted as a mainstream specialty; it is influencing care across the NHS. In Wales a care pathway, developed from the work of Ellershaw and colleagues (2), is being rolled out across the whole region, throughout various care settings, including acute hospitals and nursing homes. The aim is to improve care of the dying patient through implementation of agreed evidence-based clinical guidelines, facilitated by the introduction of the care pathway. The Clinical Effectiveness Support Unit and the National Assembly of Wales are supporting the process and evaluation. The pilot study in Bangor has demonstrated significant changes in practice, with improved analgesic prescribing. The availability of analgesics as required for pain control rose from 72% to 98% when the care pathway was implemented. The Care Pathway hence anticipates potential problems and empowers carers and nurses to give timely and effective interventions. The pathway ensures that the diagnosis of ‘dying’ is not attached inappropriately, either too early or late. The relatives are informed of anticipated events and retain choices and control. We agree with many of the principles of a good death (3); indeed they underpin the pathway. We do not prescribe a lingering death, but all must be aware that the very precise moment of death is unpredictable and not in our nor anyone else’s control. Yours faithfully Andrew Fowell
Ilora Finlay
1. Smith R. A good death . BMJ 2000;320:129-130 ( 15 January) 2. Ellershaw J, Foster A, Murphy D, et al. Developing an integrated care pathway for the dying patient E J Palliative Care 1997; 4 (6): 210- 214 3. Debate of the Age Health and Care Study Group. The future of health and care of older people: the best is yet to come. London: Age Concern, 1999 |
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Clive Seale, Reader in Medical Sociology Goldsmiths College, University of London
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Dear Editor I would take issue with the statement that we know little about the experience of death or the state of dying in Britain today. My own work with Ann Cartwright, Julia Addington Hall, and others over the years has been devoted to answering precisely these questions. Some relevant references are listed below, and we are not the only researchers in this field, which has grown substantially over the last 30 years both in America and in Britain. Even a fairly superficial examination of the journal 'Palliative Medicine', for example, would reveal the existence of a number of studies of the quality of dying in Britain today, in both hospitals and hospices as well as other important settings Secondly, while the listed 'Principles of a good death' seem to me to be good ones, it is clear that the implied model for this kind of death is that of the person with a terminal illness such as cancer. Deaths from other kinds of conditions simply do not offer these kinds of opportunities of prediction, control, and saying farewell. Not all deaths are predictable, and not all dying people have the kinds of problems that hospices traditionally address. Again, these facts are well documented with research evidence (see the first two references in the list below, for example). Yours sincerely,
References Seale C.F. (1991) A comparison of hospice and conventional care Social Science and Medicine. 32,2:147-152 Seale.C.F. (1991) Death from cancer and death from other causes: the relevance of the hospice approach Palliative Medicine. 5: 12-19. Seale.C.F., Cartwright A. (1994) The year before death Avebury. Seale C.F, Addington-Hall J. (1995) Euthanasia: the role of good care Social Science and Medicine 40, 5, pp. 581-587. Seale CF, Kelly M (1997) A comparison of hospice and hospital care for people who die: views of surviving spouse. Palliative Medicine 11: 93- 100 Seale CF, Addington-Hall J, McCarthy M (1997) Awareness of dying: prevalence, causes and consequences Social Science and Medicine 45, 3, 477 -484 Seale C.F. (1998) Constructing death: the sociology of dying and bereavement Cambridge University Press |
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Susan Elizabeth, Director of Grants Kings Fund
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Dear Sir, Your leader, A good death (15 January 2000), raises many timely challenges to one of the late 20th century's greatest taboos - the willingness to face our own mortality and the inevitability of death. The King's Fund has become increasingly concerned, over the past five years, with the quality of death achieved by people in the UK. As your article implies, there appears to be plenty of evidence that what you are dying of, where you die, and what your culture is, will have a great deal of impact on the quality of your death. The King's Fund believes there is a need to focus on the dying person - not their carers or the bereaved, whose needs are different and, generally, better recognised. Aside from issues of the clinical care of the dying, there is a need, in an increasingly secular world, to respond to the underlying human need to meet death in an "integrated" state, having made sense of one's life as something more than a random series of events, to be psychologically "whole". As part of the Fund's programmes to mark the Millennium, we are about to undertake the first ever survey of the psycho-social support available to dying people in London, and of the social, judicial and cultural context for death as we enter the new century. Later this year a series of seminars and articles will open the issues to a wide audience. We intend that the debate will extend beyond the health and care professionals, and embrace the general public, whose views on this most universal of issues are largely untapped. In this way, we aim to answer the question at the heart of your leader "what is the state of dying in Britain today?". The answers are of profound importance to us all. Yours truly, Susan Elizabeth
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Mamoun Mobayed
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Editor, I very much welcome the main principles of the editorial "A good death" 1 but the article makes a reference that "Earlier Arab and Jewish doctors had thought it blasphemous for doctors to attempt to interfere with death." If the author is referring to Muslims, then it is useful to mention that Arabs are only 20% of Muslims, and the rest are non-Arabic speaking Muslims. When the Qura'n speaks about death, it even mentions it before life itself to signify its importance, "it is He (God) who has created death and life that He may try you, which of you is best in conduct." 2. Muslims were asked to interfere with death and try preventing it as much as possible. "And if anyone gives life to another person (preventing death), it is as if he had given life to all mankind" 3 and that is why Muslims were advanced in medicine. Muslims in the UK are the second largest religious group after Christians. Muslim Doctors and Dentists Association is holding in Birmingham a one-day conference on 'Medical Ethical Issues: An Islamic Perspective' on the 12th February 2000. There will be four themes; care of the dying and euthanasia, human genetics and cloning, organ transplant and donation, and fertility and pregnancy issues.4 Mamoun Mobayed 1 Smith R. A good death. BMJ 2000; 320:129-130. (15 January.) 2 Qura'n, (67: 2) 3 Qura'n, (5: 32) 4 Muslim Doctors and Dentists Association, Office contact: M. Haffiz, Tel: 0121-5449757 |
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M Anne Chamberlain
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Last year my husband died. Thanks to the support of our general practice and the local hospice, he died at home, peacefully, cared for by those who loved him and listening to the music he loved. This good death has helped his family as they learn to live without him. It is of the greatest importance that doctors and, indeed, other NHS staff are so trained that they can help patients die well. Hopefully they will also recognise their accomplishment when they have done so. M Anne Chamberlain
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Ann Bowling, Professor of health services research University College London
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A good death The state of research on dying: It is true, as Richard Smith points out, that no-one can answer the question:'what is the state of dying in Britain today?' (BMJ Editorial, 2000; 320:129-130 (1)). Unfortunately, the current fashion for evaluative studies of health services, and the low priority given by grant bodies to descriptive and needs-based research, means an increasing ignorance about health, disease, dying and society, and patients' and carers' unmet needs. NHS R&D grant bodies continually reaffirm their position that they do not and will not fund ‘health needs assessment’; descriptive research tends to be bundled together under that label and generally rejected. It is argued that 'needs assessment' should be funded internally by trusts and districts. It is unlikely they are going to prioritise 'the experience of death'. The focus in health service research is on the costs and outcome of treatment for the living. The dying and their carers are sadly neglected. Admittedly, surveys of terminal care, including bereavement, have been conducted. But these (even the national study conducted by myself), by the very nature of their design, are fairly superficial; none even begin to provide an understanding of what the death itself is like for the dying or bereaved person (2). And none can be used to prepare carers to help those who are dying. Nor do existing evaluations of the relatively scarce terminal care teams provide any depth of understanding (these usually involve staff rating their own success at pain relief of the dying patient, and so on - with much potential for bias). Richard Smith's list of 'Principles of a good death' are timely and greatly welcomed. But more than this is required to 'empower' the dying person and their carer, particularly if the death takes place at home where professional help is not necessarily speedily available at times of need (eg. increasing pain). It is unlikely that the public will want to face up to the possibility of their own death, or that of a loved one in advance of the impending event. They are unlikely to want to seek out preparatory reading material on dying in advance - it is threatening and negative. But by the time the death is imminent, it is probably too late, amid the distress, to start searching for information about preparation for the end stages. In the case of increasing cancer pain, it is too late to independently discover the existence of, and suddenly request, an often scarce patient-controlled syringe driver (for diamorphine) if this has not been supplied. In the case of a pressure sore it is too late to request a special cushion - when they take three weeks for delivery and the patient may only have a week or two to live. But information on how to help the dying person, on what equipment is needed, and on how to cope in distressing situations is essential for a 'good death' and for a less traumatic aftermath for the bereaved. It is too late to say 'Sorry' to the dead person if one gets the last stages wrong. Richard Smith suspects that the experience of dying in an acute hospital is probably 'bad' (1). One implication is that this preparation is unlikely to be provided in hospital settings. Where people are fortunate enough to have access to a hospice they may be given support, information and preparation. Where the dying person is cared for at home, if they are very lucky, a terminal care support team, together with Marie Curie nurses, and supported by a good Macmillan nurse, may provide this. I suspect in a large number of home deaths, this does not happen and the end stages are unnecessarily distressing. This is inevitable when terminal care services are so patchily provided throughout Britain, and the NHS relies on charity to provide the bulk of them. A personal view: This is not a value free commentary. I speak as one who recently cared (alone) for my 79 year old father, who died at home from stomach cancer in a rural part of Eastern England. Although there was a remote Macmillan nurse, whose role was to manage care 'but not visit', there was no terminal care support team (just the GP and a district nurse) and we were denied access to Marie Curie nurses on grounds of their scarcity. The outcome was no access to a patient-controlled (as opposed to nurse controlled) syringe driver for emergency pain control, and no pressure area care (or equipment, eg. special cushions, mattress top) and in practice there was no easy and quick access to a doctor or nurse at times of need. When the doctor last visited us (four days before the death occurred) he expressed his opinion to me that 'it would not be long now'. When I asked what to expect, and what to do to help my father, I was simply told (albeit in a kind and caring manner) 'Everybody's different' and 'Just take each day as it comes'. In the event, this advice, although well intended, led to avoidable feelings of helplessness and distress in the face of my father's increasing pain, incontinence and chain-stokes breathing, and to feeling inadequately supported (a fact not helped by great difficulties getting through by telephone to the emergency doctor and nurses). This is 'care for the dying at home' in the face of a patchy infrastructure for terminal care in this country. Maybe it is an isolated case – I suspect not, but, in any case, it is one bad experience too many. References 1. Smith R. A good death. Editorial. BMJ 2000; 320:129-130. 2. Bowling A, Cartwright A. Life after a death. A study of the elderly widowed. London:Tavistock Publications, 1982. Ann Bowling, BSc, MSc, PhD, HonMFPHM Professor of health services research University College London 4th floor, 222 Euston Road London NW1 2DA |
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Sheila Barnfather, Consultant's Secretary Royal Wolverhampton Hospitals
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Whatever happened to the trust the public had in the general practitioner to have life under control, pain under control and the ability to maintain the flicker of life in comfort and more often than not, fan the flame so that each day has some pleasure and enjoyment. I write not becuase some mad-Shipman has rocked the boat of the medical profession but because your leading article (BMJ: 320. 129-30 January 15th 2000) which could be considered unfortunately timely, gives an emphasis on death which can only be described as "unhealthy". There are so very many positive aspects of medicine as the new century begins: research which will bring benefits to those suffering from all manner of diseases. Of course, we shall all die before the century turns but do we really have to undergo all this preparation for it. It seems to me that things have moved on since the philosophy of Epicurus and Montaigne. If you medical readers actually take your death principles on board and have their patients so prepared I can only anticipate that this will do the Pharmaceutical industry a power of good in the increased sales of antidepressants and increase the workload of Psychiatrists unnecessarily. Sheila Barnfather
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Margaret Brown, Lecturer University of South Australaia
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Richard Smith states in his editorial, " there is a suspicion that for the majority who die in acute hospitals or nursing homes the experience is bad." He refers to anecdotal evidence from newspapers and a study that was carried out in 1983 by Mills et al.(1) Similar stories abound in Australia even though we have well developed Palliative Care services. However, palliative care is only accessible to some terminally ill patients and usually only those who are dying of cancer. The not "good dying" in hospitals still seems to be a common experience in most western countries as indicated by a recent bequest in Toronto, Canada.(2) Research commissioned in 1991 by the South Australian Parliamentary Select Committee on the Law and Practice Relating to Death and Dying (3) found that the majority of respondents considered that public hospitals were unsatisfactory in the provision of care for terminally ill patients. The majority of respondents felt very excluded from medical decision making and a third of the respondents often or always had problems with communication and feedback from hospital specialists. This evidence, which echoed Mills et al research, and other anecdotal evidence prompted a group of researchers in South Australia to investigate the care of terminally ill patients in the acute hospital setting. A preliminary study was conducted in 1997 to observe the care given to 10 terminally ill patients during their last 6 days of life in medical wards within two acute care hospitals. The findings indicate that there are several barriers to the provision of care when patients are dying in this setting, such as strict adherence to routine and the lack of shared and consistent terminology to inform those providing the care in the hospital.(4) This study has been followed by a larger study using a similar methodology including interviews with staff involved in the caring. The findings indicate that care of dying patients observed, ranged from excellent to inadequate. The care was often undertaken by inexperienced health professionals without the understanding of the philosophy of palliative care or the skills required to provide this care. Dying patients were routinely moved to 'side rooms' in very busy wards as staff thought that this provided privacy and protected the other patients from witnessing the dying. However, the observational data revealed that it could be a very isolating experience for the patients and those who were unresponsive were sometimes left for long periods without attention. The presence or absence of family members influenced the amount of care received by the patient as the care family members provided was included in the data.(5) The results of these two studies suggest that the principles of palliative care are yet to be included in the culture of the acute hospital setting. It is as though the hospital environment reflects the hussle and bussle of everyday life in society which still denies the naturalness and inevitability of death. There is no provision for an "amicus mortis" in an acute care hospital if a family member is unable to be present.(6) Many people die alone in the midst of all the busyness. Where to from here? The questions go beyond the boundaries of medicine and belong to the human race. Whilst the sanctity of life is overridden so often by the culture of war, where wars and violence rob humanity of lives daily and death is portrayed as a successful outcome, we will continue to live with a paradox. Perhaps there are bigger questions still to be asked about death and dying in society before the hospital death is tended to with the humanity and compassion we desire. I for one hope my last few days of life are not alone in a side room in an acute hospital setting. But I welcome the debate both in the medical journals and in all facets of society References: 1. Mills M, Davies HTO, Macrae WA. Care of dying patients in hospital. BMJ 1994; 309: 583-586. 2. News release Department of Public Affairs University of Toronto 1999 (2nd February). 3. Report prepared for the South Australian Parliamentary Select Committee on the Law and Practice Relating to Death and Dying, November 1991. 4. Pincombe J, Brown M, Thorne D, Ballantyne A, McCutcheon H. Care of dying patients in the acute hospital: An exploratory study. 2000 Progress in Palliative Care (in press). 5. Pincombe J, Brown M, Ballantyne A, Thorne D, McCutcheon H Care of dying patients in the acute hospital setting. 2000 Report to the NHMRC. University of South Australia. 6. Grogono J. Sharing control in death, find an "amicus mortis". BMJ 2000 320: Letter (20th January). |
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D Nelson
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I much enjoyed the leader 'A Good Death'. It should be required reading for lots of people in and out of the profession. I was a doctor with The Parachute Regiment from 1942 till 1945. I saw North Africa, Sicily, Italy, France and the Rhine. Many friends were killed and the lingering were helped to as good a death as possible. I well remember a dear friend who was the Major commanding HQ Company of the 1st Canadian Parachute Regiment. We landed in Normandy together and while establishing our position came under heavy fire. The worst was a mortar searching us yard-by-yard - any soldier will know what I mean - it got us. My problem was trivial, Murray's were near fatal. He was a very serious officer and always worried to get things done. All the mess would shout 'What's the Worry, Murray' when he arrived looking gloomy. When he was trying to make us work faster on exercises we would say 'What's the Hurry, Murray'. As he lay with ghastly wounds I smacked a heavy dose of morphia intravenously, put my arm around his undamaged shoulders and said 'What's the Hurry, Murray'. He smiled as he died. I soon learnt why Nelson said: "Kiss me Hardy". Death is a fine and private thing. In those years I saw too many - of my 40 men only 2 survived till 1945. Three died by what the Americans called friendly fire (this of course was towards the end of the War when they could see we would win without them - so they joined) I would like to tell of the near bad death of baby Peter Finch who lived for a good life. Also of Courtney Gage (The greatest Doctor I knew - and I knew Lord Moran, Arthur Porrit and Watson Jones) who died a good death with much love. I adored pussy cats since babyhood. In early 1944 I was in a bus with the Brigadier and some 30 officers going to a briefing. A silly pussy ran in front and was hit. The Brig. shouted: 'Go look, Doc'. Its back was broken and it was mewing. I pulled out my handgun and shot it. When I got back in the bus the Brig said: 'I wont come to see you with bad feet Doc'. He then added after the lads had made comment 'But we need you in France'. We all knew what he meant and I muttered a thank you Sir. It was there I saw a very bad death. I was a prisoner in Rennes in late June '44. One morning a German Army Doctor arrived and took me into the town (I was hit by two stones thrown by local French during that short walk) into a tiny prison cell where a man lay on straw palliase. The light was poor, the stench appalling and the young man terminal. His legs to mid thigh were black rubble. The doctor told me he had been beaten with a rubber truncheon every day progressively from the feet up as he was a known resistance fighter. He told me I could give morphia but he wasn't allowed to. I touched the poor sod, who was conscious, and as I was in full uniform stood back to attention and saluted. I then gave the lethal dose. In 1970 I was invited - almost a 3 line whip - to 6 pm drinks with a very good GP. He had spent 4 years as a POW after Dunkirk when he stayed with his wounded. A man of many convictions which embodied his ethics as a doctor. It was a funny party - all professional men including a catholic GP and 3 magistrates. At 7 pm he called us to order and stated: 'I am now going round to carry out the wishes of Mrs X (a lady we all knew). I will say goodbye from you all as I inject her.' It was typical of Norman - courageous and a challenge. The challenge was not taken up and we all went to the funeral. In contrast are most deaths I have seen in England recently. In the Hospices very good but in the hospitals not wonderful. BUT the plea I would make is against the deprivation of their drug to the obviously dying. An alcoholic friend who drank almost a bottle or whisky a day was dying of an unrelated condition and his loving family when he could no longer walk gave him one small whisky a day for the 6 ghastly weeks it took him to die. On many occasions I have seen heavy smokers deprived of cigarettes for their last few weeks of life. I know no hard drug users but I suspect many are also cut off terminally. PLEASE add to the basic laws of a good death - No unnecessary stopping of their drug. Dr D. Nelson
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