Intended for healthcare professionals

Letters Challenge of talking about death

The limits of palliative care

BMJ 2014; 349 doi: (Published 01 July 2014) Cite this as: BMJ 2014;349:g4285
  1. Graham Winyard, former deputy chief medical officer1,
  2. Liza Macdonald, retired consultant radiotherapist2
  1. 1Winchester SO23 9TE, UK
  2. 2London W1G 6QS, UK
  1. grahamwinyard{at}

Patients wanting the sort of open discussion about their impending death that Boyd and Murray advocate will have one topic denied them; taking their own life should palliative care prove ineffective.1 This option is important because the medical literature demonstrates clearly the limits of even the best palliative care.2 The medical and religious establishments accept this but contend that the suffering of a small number of individuals is a necessary price to pay to protect the vulnerable.3 4 Discounting daily suffering against hypothetical risk seems dangerously complacent without knowing the numbers involved. How small is this small number? Society needs to understand the full price it is requiring some of its members to pay for the general good.

To date, no surveys have examined directly the frequency of such refractory suffering. The latest National Bereavement Survey (VOICES) of end of life care in England, however, offers a way into the question. Even in hospices, where we can assume that excellent palliative care is available, more than 2% of patients with pain were reported as experiencing no relief during their last three months of life.5 Figures for poor pain control and poor relief of other symptoms in the last two days of life are similar.6 Extrapolation from this, excluding sudden deaths and those with only a short preceding illness, suggests that at least 6000 adults would experience severe distress while dying, every year in England, even if excellent palliative care were universally available. This seems a high price for society to pay, and certainly one that requires better informed consent by the public. This level of suffering would help explain the degree of public support for the option of an assisted death, in spite of the acknowledged excellence of our palliative care services.

These figures require confirmation, and the obvious way is to undertake a proper study, to inform the public and its legislators. The risks of changing the law on assisted dying are theoretical; the daily suffering is real.


Cite this as: BMJ 2014;349:g4285


  • Competing interests: GW is a member of the Dignity in Dying Board and GW and LM are members of the Healthcare Professionals for Assisted Dying Steering Group.


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