The Knights of St Columba invited me to speak today on the question of secularisation in Britain today. I focussed particularly on the effects of discrimination legislation but also examined briefly how the "conflicting rights" question can be applied to other pro-life matters. (Sorry that I can't publish the lecture as yet - it still needs some tidying up.)The other speaker was Dr Gillian Craig, a retired Geriatrician who has written extensively on the question of hydration and palliative sedation of the elderly. I found her lecture most informative. It was a worrying confirmation of many concerns that have arisen in the debate over the Mental Capacity Act.
Britain has a problem with its ageing population and decreasing provision for the elderly. The closure of long stay wards in hospitals means that there is a need to reduce the numbers of elderly being admitted to hospital and a need to discharge patients wherever possible. Managerial pressure to increase the bed occupancy rate has led to an institutional prejudice against the elderly who can be seen as "bed blockers".
The current approach is to discourage admission to hospital for the dying and encourage palliative care in the community. A significant problem is that many elderly people become dehydrated for various medical reasons and need careful nutrition and hydration. Dr Craig spent many years trying to persuade colleagues that hydration is a basic need for patients. Sadly, as we know, artificial hydration has now been redefined as treatment. This began with the case of Tony Bland and has since been extended from long-term PVS patients to being a routine definition with the Mental Capacity Act.
Although it used to be accepted that a blanket policy to withdraw hydration was unethical, this has now changed with the publication of "Changing Gear - Managing the last days of life in adults" and the NHS Integrated Care Pathway which is much less positive on the question of artificial hydration: often seen as inappropriate intervention even when there is no medical reason to suppose that hydration would be other than a good. The new policy does not recognise that subcutaneous hydration can be given in the community. Craig emphasised that it is necessary for nurses and GPs to learn how to administer subcutaneous hydration. This procedure is nowadays often omitted because it "prolongs dying". As Dr Craig pointed out, this is a sinister alternative to the more obvious point that it prolongs life.
One interesting point was that patients in care homes can now be asked as part of the programme of targeting care to fill up a "preferred place of care document" ("where would you like to die?" in other words.) Most people will, of course say that this would be at home rather than in hospital. However, this is a double-edged sword because your expressed wishes could be used to prevent you from becoming a "bed-blocker" and receiving reasonable treatment that might otherwise prolong your life.
Another development is that "hospice style" care is delivered in the community. This can include routine sedation, and the anticipatory prescription of drugs such as diamorphine and haloperidol in advance in order to manage the process of dying. This procedure of "anticipatory prescribing" was the focus of a police investigation several years ago at the Gosport War Memorial Hospital. (See this notice from Alexander Harris solicitors.)
Palliative sedation is, of course, appropriate in some cases if the patient has intolerable symptoms and is at the point of death and the intention is to relieve the symptoms. This is very different from the anticipatory prescription of diamorphine in order to hasten a "good death". It is right that the police should be called in such a case but if such measures are adopted routinely in care homes for the elderly, it is unlikely that any but well-informed relatives will have any redress.
If you are in the UK and are elderly or have an elderly relative, you would be well advised to be join SPUC's Patients First Network.
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Here in Western Australia our Health Minister ( who comes from a Catholic family but who is now as anti-Catholic as is possible ), is pushing forward "Living Wills" which is a backdoor way of introducing Euthanasia. By means of these "wills", the elderly and the not-so-elderly can declare their opposition to any palliative care. Indeed it assumed that palliative care is not required unless specifically asked for. These things are to be pushed onto the unsuspecting, to sign without knowing what they are signing.
This same politician is also the State Attorney General and he is also pushing for legalised brothels.
JARay
The Canons Regular of St John Cantius in Chicago (www.cantius.org) celebrated the Nativity of the B.V.M with a Tridentine Latin High Mass. After Mass the traditional Blessing of Seeds was given from the Rituale Romanum 1962. The Canons also celebrated today the 100th anniversary of "Pascendi," the encyclical of Pius X condemning Modernism, the heresy of all heresies. They lead the faithful in renewing their devotion to Our Lady and to the Church by professing the "Oath against Modernism" of Pope St Pius X.
Learn the Latin Mass at
www.sanctamissa.org
Frightening..it makes me afraid to get old...
You will keep me informed about these lectures when they are coming up so I can go to them and bring my snazzy new digital voice recorder, won't you?
Whilst it is certainly true that hydration is ordinarily a basic human need, the metabolism of a dying patient – and I emphasise a patient who has reached an irreversible state of advanced disease with progressive loss of function, extreme irreversible weakness and organ failure – is very different from that of a non-dying patient and since catabolism causes the production of water and CO2 from stored body reserves (and much else including changed of use body fats and liver glycogen) – the blanket statement that all patients require artifcial hydration at the very end of life is not true. Indeed there are situations (such as hyponatraemia, brain metastases and end-stage heart failure) artificial hydration would hasten death. Of course for those who are elderly and unable to eat and who are otherwise not dying require hydration in whatever form is possible (subcut fluids, nastgastric tube etc) – this is unequivocal - but the situation for the demonstrably dying is more nuanced.
”Changing Gear” is a document I have on my desk in front of me as I write: not one of the authors would be in favour of euthanasia and indeed I have heard Irene Higginson speak eloquently and sensibly about this (Higginson IJ. Euthanasia - not an option for doctors. BMA News Review 1997;8:10). It is a collection of evidence that relates to patients in the last 48 hours of life when very different rules apply. Subcut drugs including hydration can be and are given in the community – it usually requires the sensible intervention of a specialst palliative care nurse. As for the NHS Intergrated Pathway, this deserves ample praise – it is an attempt to roll out the quality of care given to patients in hospices (sometimes known as the “dying elite” to those poor souls who die in an NHS bed or nursing home). It is only started when a patient is in the very end stages of advanced disease (usually cancer) and when there are unequivocal and agreed signs that patient is dying.
However, this is a double-edged sword because your expressed wishes could be used to prevent you from becoming a "bed-blocker" and receiving reasonable treatment that might otherwise prolong your life.
Are you suggesting that staying in hospital will extend your life or get you better care, Father? The very opposite may be true. Being in hospital can be a very dangerous place! Hospitals are full of sick people (as is their nature) with dangerous infections. Prolonged hospital stays result in appalling problems – higher incidences of depression, hospital acquired infections and the like. I am anxious much of the time to get patients into their own homes or elsewhere, not because they block beds, but because care is much more appropriately given better elsewhere – be it hospice, nursing home (if the nursing home is good) or the patient’s own home (if they have the support of a good GP and appropriate services to ensure this) and always with the safety net of hospice if things go awry.
I’m really sorry to say this Father but in some of what you say you have conflated a whole lot of unrelated issues in order to make a general point about euthanasia: you must make a clear distinction in practice between patients who are clearly dying and in the very last hours of their lives and those patients who may be elderly and have weeks, months or years to live. The Integrated Care Pathway for the Dying and Changing Gear were written by palliative physicians and others for patients in the last 48 hours of life and I know none of them certainly not the principal authors - Professors Ellershaw and Higginson - who would advocate euthanasia. They would be appalled at the suggestion that their work was some sort of euthanasia by the back door (Hospice doctor warns against euthanasia)Routine sedation of elderly patients countsin law , I think, as assault and patients need the application of the law as it stands to protect them.
This is very different from the anticipatory prescription of diamorphine in order to hasten a "good death".
As for anticipatory prescribing – patients with advanced cancer are almost universally likely to get severe pain or overwhelming breathlessness –both of which can be effectively treated with opioids. If anything I am faced with the problem of patients more often than not who do not have their symptoms adequately treated with appropriate medication. Anything up to 80% of patients in the last days of life will have delirium or confusion which may require haloperidol (the only drug with any reasonable evidence to support its use - Keeley P Delirium at the end of life. BMJ Clin Evid 2007;06:2405). Most patients will have severe pain at some point. Appropriate anticipation of symptoms is good palliative care and requires good education of nurses and/or families, but most palliative physicians find anything but drugs being given in excess to “hasten” death. Most days I find the reverse – a misplaced fear of using opiates in those inexperienced in their use and a resultant presence of uncontrolled pain in terminal patients. Morphine myths abound, unfortunately –among the medical profession as much as anyone else. Morphine, diamorphine and other opiates, properly prescribed, do not kill patients and there is ample evidence to show this: Pain Control: Dispelling the Myths
There is no evidence to show that opiates in the context of the end of life hasten death (Regnard C Opioids, sleep and time of death. Pall Med 1987; 1:107-110; Thorns A Sykes N. Opioid use in last week of life and implications for end-of-life decision-making. Lancet 2000 ;356:398-9) Bad palliative care and uncontrolled pain, I’m afraid, end up with bad deaths and relatives who believe the only answer is euthanasia.
I may be mistaken or over-sensitive but you seem to be casting palliative care as the enemy here, Father. We are not. The vast majority of palliative physicians are vigorously opposed to euthanasia. I know none who are pro-euthanasia. We are very much in favour of a comfortable end for patients within the law and within all acceptable moral standards:
Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable Palliative care is a special form of disinterested charity. As such it should be encouraged.
Catechism of the Catholic Church: 2279
Sorry for the long post. As I say, it may be that I am being over-sensitive. If I am, I'm sorry, but I feel passionately that the dying need good symptom control and that the vulnerable need protecton. Both are possible.
Paulinus - thank you for taking the trouble to post that comment.
I am aware that hydration can be harmful in genuine end of life cases, that is why is used the qualifying phrase "when there is no medical reason to suppose that hydration would be other than a good". Dr Craig was concerned that many elderly people who are not dying become dehydrated and their life is shortened as a consequence.
I agree with you that hospitals are dangerous places and generally, the elderly are much better off out of them. But I smell a rat in this "preferred place of care" statement. As with any advanced directive type of document, the person does not know in advance what will be in their best interests in any given circumstance. The "right" answer to this question should surely be something like "wherever the doctor thinks I would be best off: all other things being equal, at home."
Sorry if I seemed to be attacking palliative carers. I think that Dr Craig would call for greater communication and co-operation between those involved in palliative care and geriatricians.
I fully accept that the prescription of opiates for a person who needs them will not hasten death but usually prolong life. (This was explained to me by Dr Philip Howard who said to me that the invocation of the double effect argument was irrelevant since there was not an evil effect.) The problem would be, I think, in the prescription of such drugs to those who were not in need of them, or the routine sedation of patients. The latter I have certainly come across. In one case, a parishioner who was a doctor had to throw his weight around to prevent his relatively young and health mother from being sedated every night.
Agree with everything you've clarified, Father. I'm probably just being paranoid, as usual.
Dehydration is a natural part of the dying process. Any good hospice will have a distinct lack of intravenous infusions because of this. If a patient does not want to eat and drink, that is sometimes a wish which has to be respected. Just something to bear in mind.
By a curious coincidence I've been asked to review Dr Craig's book by a journal. I look forward to it.
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