Mike's Cheeky Blog: Palliative Care, Opioids and 'Hastening a Death'
Yesterday, discussing a recent 'Horizon' broadcast and the consequences of editing, Katherine Sleeman posted a tweet:
https://twitter.com/kesleeman/status/1088740267937726466
An editor once changed my sentence ‘In appropriate doses, opioids do not hasten death’ to ‘Inappropriate doses of opioids do not hasten death’ It went to print
Now, it is obvious why Katherine wasn't happy about that - but I'm unhappy with the sentence she wrote, which is a sentence 'I keep coming across' from some Palliative Care Doctors:
‘In appropriate doses, opioids do not hasten death’
I dislike that, because it simply doesn't fit, with the Mental Capacity Act's description of the patient-doctor interaction - it seems to imply:
'If an opioid hastens death, then the dose is inappropriate'.
The Mental Capacity Act describes Informed Consent when patients are mentally capable (and the Montgomery ruling has also made this clear more recently) - and put simply, Informed Consent involves:
The doctor offering treatments which might be clinically effective, then the patient deciding whether the risks associated with the treatment, or the benefits associated with the treatment, are the more important FOR THAT INDIVIDUAL PATIENT.
It is true, and clear within the MCA (section 4(5)) that both murder and assisted suicide are both still illegal (the MCA doesn't provide a legal defence, for either, to be 'more nerdy').
But palliative care is about 'better death'.
If a patient is in what the patient considers to be 'intolerable distress', and if the only treatment which would relieve that distress might shorten the patient's life, then surely that is the patient's decision? If the choice is between:
1) Without the drug, you will probably live for about 3 weeks, in what you consider
to be intolerable distress, or
2) With the drug, your distress will be removed, but you will probably die in about
2 weeks
then WHY ISN'T THAT A DECISION FOR THE PATIENT TO MAKE?
Harold Shipman, was murdering patients: without consent, he was giving patients drugs which killed them almost immediately.
But how, is giving an opioid dose which might shorten your life from 3 weeks to 2 weeks, with your consent, even 'assisted suicide' - if I were committing suicide, then if it took 2 weeks to kill me, I would consider the method I'd chosen to be pretty useless!
The reason we need clarity on this, is something I pointed out in:
When we were discussing this on Nursing Times Online (the question being, do the clinicians not offer something like higher doses of morphine 'if the dose needed to adequately relieve your pain might also hasten your death', or should the clinicians offer you the higher does and describe the risk, and then allow the patient to decide whether to take the risk of a {possibly} shortened life ?'), and a Mental Health Nurse who posts as Tinkerbell wrote:
'...all I can say is that if I am in excruciating pain without any hope of making a recovery as I have a terminal illness then I would like as much pain relief as I can have to relieve my pain even if it kills me.
If I have the potential of making a recovery then I would want as much pain relief as I can tolerate without it killing me.
I would certainly hope that if that situation occurs I will not have a team unsure of what to do debating it whilst I scream out in pain 'for Gods sake somebody please help me'.'
Now, WHEN you are dying in agony, is definitely NOT the time for you and your clinicians to be debating the finer points of the law around assisted suicide, etc, which in this situation many clinicians seem to be worried about {leading to different behaviour from different clinicians in similar clinical situations} - clinicians and patients need to get these issues clear, and openly published so that patients and relatives can understand what they will be offered, in advance.
I could go on - we could consider incapacitous patients and MCA best-interests, and the psychological aspects [for the doctors] of offering treatment which they know would probably shorten the patient's life - but I'm keeping this short.