My journey from anti to pro assisted dyingBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4592 (Published 09 July 2012) Cite this as: BMJ 2012;345:e4592
All rapid responses
In the ongoing debate about assisted suicide1, 2, we should not lose sight of some key facts about good care in the last days of life. Whether or not we use a document such as the Liverpool Care Pathway for the dying patient (LCP) or, in Wales, the Integrated Care Priorities for the Last Days of Life (ICP-LDL) to guide and record our care of the dying, there is nothing that leads to “a protracted form of assisted dying”2.
The LCP and ICP-LDL do not involve a protocolised withdrawal of fluids. Both are consistent with the guidance3 from the General Medical Council (GMC) in the UK that the balance of benefits, burdens and risks must be considered and when they are “finely balanced [in a patient with capacity], the patient’s request will usually be the deciding factor.”3 para 117 In a patient lacking capacity, for parenteral fluids as for any treatment our decisions “must be based on whether the treatment would be of overall benefit to the patient.”3 para 13
Care of the dying should not “entail increasing sedation”2, which is not prompted by the LCP or ICP-LDL, or advised in their accompanying guidance. Even as a side effect of drugs for symptom control, iatrogenic sedation can usually be kept to a minimum. Exhausted patients sleep comfortably when their physical, psychological and spiritual distress is relieved but they retain the ability to rouse and communicate at will, as far as their disease allows. As for our actions being “medically determined”2, the GMC’s guidance3 tells us that we should include patients in decisions, maximising their capacity to participate, and that in “making a decision about overall benefit [a doctor] must consult with those close to the patient who lacks capacity, to help [the doctor] reach a view.”3 para 13 The ICP-LDL and LCP are again consistent with this guidance. We should not shrink from making tough medical decisions but they must be grounded in assessment of individual needs and wishes.
We need best practice guidance, such as the LCP and ICP- LDL, to inform and deliver the care of the dying in accordance with NICE guidance4. Treatment that does not respect the patient’s needs or involves the inappropriate use of sedation is not controversial. It is simply bad medicine and falls short of GMC guidance. Any of us aware of poor care for dying patients has a responsibility to help root it out. Only then will we ensure the delivery of the high standard of care that we would want for our patients, our society and ourselves.
Idris Baker, Lead Clinician Palliative Medicine, ABM University Local Health Board, Wales
Rosaleen Beattie, Consultant in Palliative Medicine, Western Health and Social Care Trust, Northern Ireland
Ian Cairns, Consultant in Palliative Medicine, Portsmouth Hospitals NHS Trust
Craig Gannon, Consultant in Palliative Medicine, Princess Alice Hospice, Esher
Eleanor Grogan, Consultant in Palliative Medicine, Northumbria Healthcare NHS Foundation Trust
Tim Harlow, Consultant Palliative Care, Hospiscare, Exeter
Bee Wee, Consultant in Palliative Medicine, Oxford University Hospitals NHS Trust
1 Godlee F. Assisted dying. BMJ 2012;344:e4075. (14th June.)
2 Ahmedzai S. My journey from anti to pro assisted dying. BMJ 2012;345:e4592. (9th July.)
3 General Medical Council. Treatment and care towards the end of life: good practice in decision making. http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp. (Accessed 19th July 2012.)
4 National Institute for Clinical Excellence (2004). Supportive and palliative care: the Manual. http://guidance.nice.org.uk/CSGSP/Guidance/pdf/English. (Accessed 19th July 2012.)
Competing interests: No competing interests