Forty years ago, when I was a very junior houseman, a young man was admitted for surgery to remove a large malignant bowel tumour.
Post operatively he did very badly with an ileus which persisted for several weeks, dehiscence of the wound and a leaking bowel fistula. Finally, in desperation at the lack of improvement, the consultant performed a laparotomy (no CT scans in those days) and discovered that he had galloping cancer; his whole abdomen was infiltrated with tumour and faeculent fluid.
On return to the ward the consultant simply muttered, “Don’t let him wake up”. I then witnessed the surgical registrar and the senior ward sister administer a whopping dose of opiate. The young man never woke up and quietly died within twenty-four hours. That is how things were done in those days.
This was medical euthanasia, although I would maintain that it was in fact good compassionate medicine and within the law. It was accepted in those days that the administration of large doses of opiates to relieve terminal suffering was acceptable, even though it hastened the patient’s death.
I regularly witnessed similar practice when, a year or so later, I worked at one of the well-known cancer hospitals.
But things seem more complicated these days so let me relate a different case.
Several years ago the elderly father of a friend developed severe progressive dementia. He was cared for initially by his wife with family support. However increasing age and infirmity of both necessitated his admission to a care home.
After some months in the home he became unwell and, as seems to be routine practice these days, an ambulance was summoned and the old man admitted to hospital.
After a few days of IV rehydration and antibiotics he had recovered sufficiently to be discharged back to the home. However the severity of his dementia meant that he had no quality of life whatsoever and he required total care.
Over the next eighteen months this scenario was repeated five times. On the last occasion my friend was informed of the admission and managed to get there in time to discuss with the admitting team the appropriateness or otherwise of continuing active treatment. It was agreed that the old boy should simply be kept comfortable and he quietly passed away after a couple of days. The ‘old man’s friend’ had done the job.
In my view my friend was right to intervene; the treatment administered during the previous admissions was completely inappropriate given the clinical context. But it is difficult to blame the hospital doctors – in a busy emergency department such judgements are not always practical or possible. The real mistake was the 999 call summoning the ambulance.
Had the GP, in conjunction with the family and the home, made a proper care plan then the old man could have had a quieter and more dignified end in his own bed.
On Friday 18 July, their Lordships debated Lord Falconer’s assisted dying bill. I don’t want to rehearse all the various arguments other than to say that, in my opinion, to ignore the strong views of many disabled individuals and groups would seem to me to be foolishness in the extreme. I also think that the well-known adage ‘hard cases make bad law‘ is totally apposite in this case.
But the clincher, in my view, is the ’six months’ prognosis. Any sensible doctor knows that that is daft!
But it seems to me that society is confused and divided on this, and I accept that these issues are very complex. We spend ever increasing resources on investigating and treating a patient whose life is clearly coming to an end while vociferous groups are campaigning for assisted suicide and euthanasia.
These days it seems impossible for many to die without having multiple investigations, and I witness this on a daily basis as frail elderly folk or the terminally ill are wheeled in for yet another scan which will make no meaningful difference to the outcome.
This week, during a busy ultrasound list, I was asked by a junior if I would urgently scan a patient with acute kidney injury. I normally agree to such request on the grounds that it may significantly alter acute management. However the patient they wheeled in was a demented 92-year old! My report simply said, “92-year-old kidneys”!
These days it seems that every confused elderly patient brought in by ambulance will have a cranial CT scan on the rational that “we might miss something” or “please exclude a ….”, and every patient with mild SOB will have a CTPA to exclude a PE. There seems to be little joined up diagnostic thinking.
Please don’t get me wrong. Of course I fully support appropriate investigation of patients, irrespective of age and infirmity, but the emphasis is on the word “appropriate”!
There does need to be a discussion in our society around the end-of-life issues, but I am not convinced that the debate so far is rational. It seems to me that the case supporting Lord Falconer’s bill rested heavily on emotion and “hard cases” rather than rationality.
We are told that 69% of the population support assisted dying but then 60% would like to see the re-introduction of capital punishment! Should we go with the crowd or what? Those who oppose the re-introduction of the death penalty do so because they believe it is wholly wrong in principle, and those opposed to assisted suicide do so on the same basis.
Of course the assisted suicide bill is completely different from the case I described initially, but I for one would be deeply unhappy if our society chose to choose the slippery slope of assisted dying. Instead let us find a middle way of protecting the vulnerable while not striving officiously to preserve poor quality life at all costs.
“Thou shalt not kill; but needst not strive officiously to keep alive.”