Dying with Dignity

1
Dying with Dignity

• Susan Wilson
• GPVTS 24/01/2008
• With acknowledgment to Elaine Murphys
  presentation at RCGP Annual Conference

2
Introduction

• Suicide Act 1961 decriminalised suicide
• Failed attempt could no longer be prosecuted
• However a person who aids, abets, counsels or
  procures the suicide of another, or attempt by
  another to commit suicide, shall be liable on
  conviction to imprisonment of a term of up to 14
  years

3
Introduction

• Human rights Act 1998 states that everyones
  right to life should be protected by law.
• No one shall be deprived of his life
  intentionally save in the execution of a sentence
  of a court
• Challenge by Mrs Pretty lost as refusal to
  consent to treatment even if death will ensue is
  not the same as ending ones life

4
Values

• All patients are intrinsically valuable, no
  matter how disabled. A doctors role is to strive
  to improve the quality of life
• A request to die is a communication that has many
  different meanings
• A doctors primary role is to relieve suffering,
  not to preserve life at all costs

5
Choice at the End of Life

• Everyone should have a choice at the end of life.
  Palliative care should be patient-led.
• End-of-life decision making should be open and
  honest. Under control of patient.
• Choice for terminally ill people should include
  medically assisted dying within strict legal
  safeguards

6

• British Social Attitudes Survey 2006 82
  Support ADTI
• GP Net 2005 62 doctors say yes to
  intentionally hasten death

7
Other Countries

• Switzerland has loophole in suicide laws and
  includes non-residents
• Oregon, USA has death with dignity act. Only
  permits assisted suicide and only for residents.
• Holland and Belgium allow voluntary euthanasia as
  well as assisted suicide. Also only for
  residents.

8
What is legal in UK now?

• Suicide have to be able to do it
• Advance directive to refuse treatment
• Double effect
• Terminal sedation

9
Dignity in Dying

• Campaign organisation (formerly VES) seeking
  greater choice for patients at the end of their
  life
• Feel that choice of when and how to die should be
  a basic human right

10
Dignity in Dying

• This year 2007 has seen some terrible cases of
  people's wishes at the end of life not being
  respected. The fact that over one half of all
  complaints about the NHS are about end-of-life
  care is unsurprising. Access to palliative care
  is a postcode lottery and the service you receive
  depends on where you live. People with a terminal
  illness and who are unbearable suffering are
  denied the right to an assisted death and have to
  consider an unacceptable, morbid pilgrimage
  across Europe.
• Ashley Riley, Head of Campaigns

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Dignity in Dying

• "The implementation of the Mental Capacity Act in
  October was a positive step forward in ensuring
  greater patient choice at the end of life, but
  the UK still has a very long way to go. Assisted
  dying should be a basic right for terminally ill,
  mentally competent adults who are suffering
  unbearably. Excellent palliative care should be
  available to all those who need it. More
  awareness of the importance of advance decisions
  is vital to ensure everyone has the best death
  possible."

12
Dignitas

• Founded May 1998 Ludwig Minelli
• First assisted suicide took place in Oct 1998
• Clinic in Switzerland but accept non-residents
• In 2007, 70 Britons travelled there to end their
  lives

13
Swiss Law

• "Whoever lures someone into suicide or provides
  assistance to commit suicide out of a
  self-interested motivation will, on completion of
  the suicide, be punished with up to five years'
  imprisonment".
• Dignitas interprets this to mean that anyone who
  assists suicide altruistically cannot be
  punished.
• Its specialist staff all work as volunteers to
  ensure there can be no conflict of interest.

14
Steps to Take

• Join Dignitas as a member (registration fee plus
  annual membership)
• Send personal letter of request explaining
  reasons. Need to include medical file containing
  diagnosis, therapies and prognosis (medical
  examination within 2 months) and CV

15
Steps to Take

• Dignitas finds a Swiss physician willing to
  prescribe lethal medication (phenobarbital)
• Obtain recent copies of all documents (birth
  cert, marriage cert, divorce decree etc)
• Once documents are with Dignitas an appointment
  can be made

16
Steps to Take

• Member will meet physician who must assess
  capacity and explore any other possibilities eg
  analgesia
• Individual must be capable of making final act
  himself (drinking barbiturate solution,
  self-injecting prepared solution etc)
• Retain control of the act to the end
• Average time scale is 77 days

17
A nurse sits with the patient, but cannot
actually help
18
Assisted Dying for the Terminally Ill Bill

• Lord Joel Joffe
• Bill to enable an adult who has capacity and who
  is suffering unbearably as a result of terminal
  illness to receive medical assistance to die at
  his own considered and persistent request

19
ADTI Bill

• Would be lawful for a doctor to prescribe
  medication and provide a means of
  self-administration (if oral not possible or
  appropriate)
• Members of healthcare team to work with the
  doctor
• Certain conditions must be satisfied

20
Conditions

• Doctor must be informed in a written request,
  signed by patient, that he/she wishes to be
  assisted to die
• Satisfied that patient does not lack capacity
• Determined that patient has a terminal illness
• Concluded unbearable suffering
• Informed the patient
• Ensured palliative care available
• Recommend patient notifies next of kin
• Satisfied that request is made voluntarily
• Refer to consultant

21
Problems with the Bill

• Unwieldy? Too much hassle?
• Which doctors?
• Remove illegality of assisted suicide instead
• Review illegality of intention to kill by double
  effect if patient states wish to die

22
Who wants to die?

• Unusual few?
• The 2900 annual double effect deaths (Seale
  2004)
• The Ive had enough doc thousands

Diane Pretty
Kelly Taylor
23
Outcome

• Lords select committee reported April 2005
• Called for a debate in next parliamentary session
  (2004/5 session cut short by election)
• Report recommended changes to the bill

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Changes

• Assisted suicide and euthanasia dealt with
  separately
• Term unbearable suffering changed to
  unrelievable suffering
• Conditions for assisted dying should be
  specific to clinical practice
• Actual procedures doctors should follow must be
  clearly stated
• Lord Joffe to draft a new bill after full House
  debate

25
Against the Bill

• Sanctity of life
• Dying is a part of life
• Erodes doctor-patient relationship
• Relationship should be open and honest
• Need to assess capacity
• MCA requires us to assess capacity anyway
• Slippery slope
• Not the experience from other countries
• Effect on vulnerable groups
• Patients in Oregon and Holland aged 50s and 60s
• Palliative care would be better
• Part of palliative care, provides reassurance

26
?
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Summary

• End-of-life choice is still a contentious issue
• Not yet in statutes in UK
• Other countries have different legislation