Download - Dying with Dignity

Dying with DignityDying with Dignity

Susan WilsonSusan WilsonGPVTS 24/01/2008GPVTS 24/01/2008

With acknowledgment to Elaine With acknowledgment to Elaine Murphy’s presentation at RCGP Annual Murphy’s presentation at RCGP Annual

ConferenceConference

IntroductionIntroduction

Suicide Act 1961 decriminalised suicideSuicide Act 1961 decriminalised suicide Failed attempt could no longer be Failed attempt could no longer be

prosecutedprosecuted However a person who aids, abets, However a person who aids, abets,

counsels or procures the suicide of counsels or procures the suicide of another, or attempt by another to another, or attempt by another to commit suicide, shall be liable on commit suicide, shall be liable on conviction to imprisonment of a term of conviction to imprisonment of a term of up to 14 yearsup to 14 years

IntroductionIntroduction

Human rights Act 1998 states that Human rights Act 1998 states that everyone’s right to life should be everyone’s right to life should be protected by law.protected by law.

No one shall be deprived of his life No one shall be deprived of his life intentionally save in the execution of a intentionally save in the execution of a sentence of a courtsentence of a court

Challenge by Mrs Pretty lost as refusal to Challenge by Mrs Pretty lost as refusal to consent to treatment even if death will consent to treatment even if death will ensue is not the same as ending one’s lifeensue is not the same as ending one’s life

ValuesValues

All patients are intrinsically valuable, All patients are intrinsically valuable, no matter how disabled. A doctor’s role no matter how disabled. A doctor’s role is to strive to improve the quality of lifeis to strive to improve the quality of life

A request to die is a communication A request to die is a communication that has many different meaningsthat has many different meanings

A doctor’s primary role is to relieve A doctor’s primary role is to relieve suffering, not to preserve life at all suffering, not to preserve life at all costscosts

Choice at the End of Choice at the End of LifeLife Everyone should have a choice at the end Everyone should have a choice at the end

of life. Palliative care should be patient-of life. Palliative care should be patient-led.led.

End-of-life decision making should be End-of-life decision making should be open and honest. Under control of patient.open and honest. Under control of patient.

Choice for terminally ill people should Choice for terminally ill people should include medically assisted dying within include medically assisted dying within strict legal safeguardsstrict legal safeguards

•British Social Attitudes Survey 2006 – 82% Support ADTI

•GP Net 2005 – 62% doctors say yes to intentionally hasten death

Other CountriesOther Countries

Switzerland has loophole in suicide Switzerland has loophole in suicide laws and includes non-residentslaws and includes non-residents

Oregon, USA has death with dignity Oregon, USA has death with dignity act. Only permits assisted suicide act. Only permits assisted suicide and only for residents.and only for residents.

Holland and Belgium allow voluntary Holland and Belgium allow voluntary euthanasia as well as assisted euthanasia as well as assisted suicide. Also only for residents. suicide. Also only for residents.

What is legal in UK What is legal in UK now?now?

Suicide – have to Suicide – have to be able to do itbe able to do it

Advance directive Advance directive to refuse to refuse treatmenttreatment

““Double effect”Double effect” Terminal sedationTerminal sedation

Dignity in DyingDignity in Dying

Campaign organisation (formerly Campaign organisation (formerly VES) seeking greater choice for VES) seeking greater choice for patients at the end of their lifepatients at the end of their life

Feel that choice of when and how Feel that choice of when and how to die should be a basic human to die should be a basic human rightright


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

Ashley Riley, Head of CampaignsAshley Riley, Head of Campaigns


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

DignitasDignitas

Founded May 1998 Ludwig MinelliFounded May 1998 Ludwig Minelli First assisted suicide took place in First assisted suicide took place in

Oct 1998Oct 1998 Clinic in Switzerland but accept Clinic in Switzerland but accept

non-residentsnon-residents In 2007, 70 Britons travelled In 2007, 70 Britons travelled

there to end their livesthere to end their lives

Swiss LawSwiss Law

"Whoever lures someone into suicide or "Whoever lures someone into suicide or provides assistance to commit suicide provides assistance to commit suicide out of a self-interested motivation will, on out of a self-interested motivation will, on completion of the suicide, be punished completion of the suicide, be punished with up to five years' imprisonment". with up to five years' imprisonment".

Dignitas interprets this to mean that Dignitas interprets this to mean that anyone who assists suicide altruistically anyone who assists suicide altruistically cannot be punished. cannot be punished.

Its specialist staff all work as volunteers Its specialist staff all work as volunteers to ensure there can be no conflict of to ensure there can be no conflict of interest. interest.

Steps to TakeSteps to Take

Join Dignitas as a member Join Dignitas as a member (registration fee plus annual (registration fee plus annual membership)membership)

Send personal letter of request Send personal letter of request explaining reasons. Need to include explaining reasons. Need to include medical file containing diagnosis, medical file containing diagnosis, therapies and prognosis (medical therapies and prognosis (medical examination within 2 months) and examination within 2 months) and CVCV


Dignitas finds a Swiss physician Dignitas finds a Swiss physician willing to prescribe lethal willing to prescribe lethal medication (phenobarbital)medication (phenobarbital)

Obtain recent copies of all Obtain recent copies of all documents (birth cert, marriage documents (birth cert, marriage cert, divorce decree etc)cert, divorce decree etc)

Once documents are with Once documents are with Dignitas an appointment can be Dignitas an appointment can be mademade


Member will meet physician who must Member will meet physician who must assess capacity and explore any other assess capacity and explore any other possibilities eg analgesiapossibilities eg analgesia

Individual must be capable of making Individual must be capable of making final act himself (drinking barbiturate final act himself (drinking barbiturate solution, self-injecting prepared solution, self-injecting prepared solution etc)solution etc)

Retain control of the act to the endRetain control of the act to the end Average time scale is 77 daysAverage time scale is 77 days

A nurse sits with the patient, but A nurse sits with the patient, but cannot actually helpcannot actually help

Assisted Dying for the Assisted Dying for the Terminally Ill BillTerminally Ill Bill Lord Joel JoffeLord Joel Joffe Bill to enable an adult Bill to enable an adult

who has capacity and who has capacity and who is suffering who is suffering unbearably as a unbearably as a result of terminal result of terminal illness to receive illness to receive medical assistance to medical assistance to die at his own die at his own considered and considered and persistent requestpersistent request

ADTI BillADTI Bill

Would be lawful for a doctor to Would be lawful for a doctor to prescribe medication and provide prescribe medication and provide a means of self-administration (if a means of self-administration (if oral not possible or appropriate)oral not possible or appropriate)

Members of healthcare team to Members of healthcare team to work with the doctorwork with the doctor

Certain conditions must be Certain conditions must be satisfiedsatisfied

ConditionsConditions

Doctor must be informed in a written Doctor must be informed in a written request, signed by patient, that he/she request, signed by patient, that he/she wishes to be assisted to diewishes to be assisted to die

Satisfied that patient does not lack capacitySatisfied that patient does not lack capacity Determined that patient has a terminal Determined that patient has a terminal

illnessillness Concluded unbearable sufferingConcluded unbearable suffering Informed the patientInformed the patient Ensured palliative care availableEnsured palliative care available Recommend patient notifies next of kinRecommend patient notifies next of kin Satisfied that request is made voluntarilySatisfied that request is made voluntarily Refer to consultantRefer to consultant

Problems with the BillProblems with the Bill

Unwieldy? Too much hassle?Unwieldy? Too much hassle? Which doctors? Which doctors? Remove illegality of assisted Remove illegality of assisted

suicide insteadsuicide instead Review illegality of intention to Review illegality of intention to

kill by double effect if patient kill by double effect if patient states wish to diestates wish to die

Who wants to die?Who wants to die?

Unusual few?Unusual few?

The 2900 annual The 2900 annual “double effect” “double effect” deaths (Seale deaths (Seale 2004)2004)

The “I’ve had The “I’ve had enough doc” enough doc” thousandsthousands

Diane Pretty

Kelly Taylor

OutcomeOutcome

Lord’s select committee reported Lord’s select committee reported April 2005April 2005

Called for a debate in next Called for a debate in next parliamentary session (2004/5 parliamentary session (2004/5 session cut short by election)session cut short by election)

Report recommended changes to Report recommended changes to the billthe bill

Changes Changes

Assisted suicide and euthanasia dealt Assisted suicide and euthanasia dealt with separatelywith separately

Term “unbearable suffering” changed Term “unbearable suffering” changed to “unrelievable suffering”to “unrelievable suffering”

Conditions for “assisted dying” should Conditions for “assisted dying” should be specific to clinical practicebe specific to clinical practice

Actual procedures doctors should Actual procedures doctors should follow must be clearly statedfollow must be clearly stated

Lord Joffe to draft a new bill after full Lord Joffe to draft a new bill after full House debateHouse debate

Against the BillAgainst the Bill

Sanctity of lifeSanctity of life– Dying is a part of lifeDying is a part of life

Erodes doctor-patient relationshipErodes doctor-patient relationship– Relationship should be open and honestRelationship should be open and honest

Need to assess capacityNeed to assess capacity– MCA requires us to assess capacity anywayMCA requires us to assess capacity anyway

Slippery slopeSlippery slope– Not the experience from other countriesNot the experience from other countries

Effect on vulnerable groupsEffect on vulnerable groups– Patients in Oregon and Holland aged 50s and 60sPatients in Oregon and Holland aged 50s and 60s

Palliative care would be betterPalliative care would be better– Part of palliative care, provides reassurancePart of palliative care, provides reassurance

SummarySummary

End-of-life choice is still a End-of-life choice is still a contentious issuecontentious issue

Not yet in statutes in UKNot yet in statutes in UK

Other countries have different Other countries have different legislationlegislation