KSC Seminar and Gillian Craig
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.
