Fillers A memorable patient

Doing the kind thing

BMJ 2005; 330 doi: (Published 31 March 2005) Cite this as: BMJ 2005;330:764
  1. Chris Burns-Cox, consultant physician (chris.burns-cox{at},
  2. Rachel Gilbert, nursing sister
  1. Frenchay Hospital, Bristol
  2. Frenchay Hospital, Bristol

    Physician's tale

    Some years ago I was asked to visit a 62 year old man on hunger strike in a prison hospital. He was awaiting trial for murder. There was no physical reason for his not eating, and neither the prison doctor nor a psychiatrist could find any evidence of mental illness. The prisoner simply felt that only by ending his own life could he approach atonement for his sin. My opinion was that we should try to encourage him to change his aim but that he should be allowed to starve himself to death if he insisted. He seemed to me to be a man of honour who knew he had made a terrible mistake.

    Over the next few days he was seen by several psychiatrists from around the country, and they all found him sane. He saw his solicitor and made an advance directive that he was not to have any investigations or medicines and that his family was not to be contacted at all. He had discussed with prison staff his care when death approached. He felt that it would be difficult for them to manage the situation and asked if he could come to hospital to be cared for towards the end.

    I saw him three times and thought through the problems there would be for the nurses. I was blessed with ward staff who had coped successfully with other difficult situations. I agreed to admit him to a side room on a general medical ward accompanied by a prison officer.

    He died 45 days later. In the interim he drank black coffee and other no-calorie drinks and, later on, agreed to be given pain relieving drugs. He was popular on the ward—for example, sending out for a birthday card for a nurse. He never wavered in his determination to kill himself. He finally died peacefully knowing he was respected by us all. I admired him for his courage and determination to see his aim achieved.

    Was it right to admit him to occupy an expensive bed for so long? Should he have been able and entitled to have his own way? Was it cruel to the nurses to have to care for someone who “broke the rules” by wanting to die “unnecessarily”?

    I never doubted that we did the right thing and was grateful for the wonderful principles and facilities of the NHS that allowed the kind thing to be done to a man otherwise suffering alone. A career in general medicine has produced many remarkable challenges but none more memorable than caring for this man. William Osler said, “Do the kind thing and do it now”—you can't do better than follow this advice.

    Nursing sister's tale

    I agreed to take the prisoner into our side room, with little idea of what it would entail. Having established that he was mentally capable of refusing treatment, I thought the situation straightforward—to provide nursing care until he died. However, he challenged many of our ideas and responses, both a nurses and as human beings. Initially, some of us felt that he was “taking the easy way out”—avoiding a long prison sentence for a crime that he admitted to. Then, as we came to know him, it became clear that he was no criminal but a man of principles and dignity.

    Possibly the hardest thing was to see him in pain when we moved him. The nurse in each of us wanted to give him analgesia and see him comfortable. He did, later, agree to have oral morphine, but I am not sure whether this was for his benefit or ours. Perhaps it does not matter.

    Throughout this time and after he died, we had the support of the hospital psychologist. Maybe more importantly, we helped each other to cope, and many were the coffee breaks spent talking about the effect of caring for someone in such an unusual situation.

    After he died, we received several letters of thanks for our care from the prison staff. This reinforced my belief that we were right to share the privilege of helping this man, who had earned our respect and admiration.

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