Friday, May 12, 2006

Confused of Ambridge

That would be me as it happens.

What are the House of Lords doing?

Well, according to my old friends on the Today Programme this morning, they are trying to make it legal for me to help some patients to die. Not just me you understand. Doctors in the UK in general. But since most palliative and terminal care in this country is quite properly the role of GPs, I feel I might be included. And I'm not sure I want to be.

Over the past couple of years, and a number of iterations, we have been in receipt of reports from the Shipman Enquiry. These have made sweeping changes to the way we are supposed to prescribe and handle controlled drugs, and even to the way we complete the paperwork needed to permit cremations. These changes are intended to make it much harder for any doctor to bump off patients and arrange disposal of the evidence, and rightly so.

Unfortunately they have also made some GPs anxious about their role in palliative care. And some patients in need of palliation more nervous about medication. This is a wholly bad thing, and makes the debate in the Lords even more relevant. If we are prevented or inhibited from providing truly effective palliation, either for fear of investigation after the fact, of through reluctance of patients to accept the very treatment most likely to work for them, they are more likely to end their lives in pain and fear and looking for a quicker end.

To an extent I suspect we as GPs need to be more confident in our ability in this area and less fearful. But with PCTs threatening to batter down the doors and investigate "overprescribers" of opiates -- as is the case in Borsetshire-- this is a trifle difficult. We cannot deny the evil that Shipman did. We cannot deny that he practised as a GP. It is right that we accept scrutiny of this area of our practice. But the tone of PCT missives, and of the media in subsequent cases where GPs prescribing has been called into question, leads us to fear we will be held "guilty till proved innocent" rather than the other way about.

Granted there is more to palliation than the provision of opiates. Terminal care, once inevitable decline has been accepted, should be all about allowing a patient to achieve the best possible end of life. I question a doctors role in actively seeking to accelerate that end. Experience has shown me that the vast majority of patients nearing the end of life are quite capable of charting their own course, with the right help. In sixteen years I have yet to have a patient ask me to accelerate their demise. I do not feel I would be able to if one did.

The day I feel I am ready to do so is the day I swap sides of the desk and seek professional help.


Potentilla said...

Dr Crippen has just done a similar post, though I don't think his is so clear as yours in saying that he doesn't like the idea of assisted suicide BECAUSE he doesn't want to be in the position of being asked to participate himself. (Yours is honest).

I don't think any doctor should have to assist in someone's suiciide if they don't feel comfortable doing so. On the other hand, I think assisted suicide at the request of a patient (with lots of provisos) should be legal (as in Holland). I don't think the possibility of making doctors uncomfortable is a good enough reason to deny any possibility of assistance to those who wish to make this choice.

I can see I am going to have to post on this myself.

Doctor Jest said...

Hi Potentilla.

I see what you are saying, and have some sympathy, but I see my role as providing healthcare, not an exit strategy. Proper palliation, well done, can handle much of the distress and the majority of symptoms at end of life.

There will always be some who feel a quicker more controlled end is for them in the abstract. And I know other juristictions allow the exercise of those options.

I would not seek to deny anybody the right to shape their own destiny, but personally I have problems with knowingly prescribing with the sole intention of ending a life.

If we become comfortable with it medically how soon before we drift into allowing it forensically, or at the behest of others for their perception of a non responsive patient's plight.

In another tangentially related matter the Human Fertilization and Embryology Authority appears to be watering down its position on eugenics. Just how consumerist do we become in these areas?

Moof said...

If we become comfortable with it medically how soon before we drift into allowing it forensically, or at the behest of others for their perception of a non responsive patient's plight."

We have to ask where the line will be drawn, and who will make the decisions?

Once this sort of thing comes to pass, I'm afraid that my trust of physicians is going to plummet ... (not to mention my respect.)

This sort of thing has deeper ramifications than meet the eye on the surface ... and each inch will only lead to another foot ...

Katy Newton said...

I sympathise with those very ill or dying people who want a quick and merciful ending, but as a patient I am against the idea of doctors being allowed to provide this sort of service, partly because I think it puts a terrible burden on the person asked to do it, partly because I can see all sorts of ways in which such a system could be abused, and partly just because I believe that doctors should be treating people and killing someone is not treating them.

Doctor Jest said...

Moof-- As you can tell I am inclined to agree. Despair is a terrible thing, but I believe it can be treated by other means than self destruction. Likewise pain, in all but a tiny minority of cases should be amenable to control. In my view treatment should always be targeted at symptoms and not simply intended to end a life.

Katy-- as Boris Johnson might put it "I couldn't fail to diasgree with you less" which if i've got the right number of double negatives in should come out as a fairly emphatic endorsement. If not it serves me right for trying to be clever, rather like Boris really. (Bugger-- just in case)....