Talking Mortality Podcast Assisted Dying Epsiode

In this episode of the Talking Mortality podcast, host Calvin Lightmurray and guest Robin Taylor discuss assisted dying from a clinician's perspective. They talk about the recent change in the British Medical Association's position on assisted dying and the survey that shows only 34% of doctors would be willing to prescribe the necessary drugs. They also share their personal experiences with patients who have requested assisted dying and the importance of providing support and comfort to those at the end of life. They highlight the difference between assisted dying and euthanasia and discuss the potential implications for the sustainability of the National Health Service. Both agree that trust between doctors and patients is crucial and that the Hippocratic Oath, which prohibits discussions about ending a patient's life, still holds value today. Hello and welcome to the Talking Mortality podcast. My name is Calvin Lightmurray. I'm the host of this podcast series. I'm a consultant doctor working in emergency medicine in the United Kingdom National Health Service. This is episode 10 and it's called Assisted Dying A Clinician's Perspective. There's been a lot of media coverage of this subject recently while here in Scotland it's also the subject of a bill due to go before Parliament to discuss making assisted dying legal. So it seems like a good time to be discussing it. The British Medical Association recently moved its position on assisted dying from one of opposition to one of neutrality. But what does this mean for the average doctor practising in the United Kingdom? A BMA survey in 2020 indicated that only 34% of doctors would be willing to prescribe the necessary drugs for assisted dying to take place. While a 2019 study demonstrated the long-term psychological impact on a number of doctors who have participated in assisted dying. Joining me for this discussion is Robin Taylor who you might recall from previous episodes in this series on the death taboo and on advanced care planning for those who might be approaching the end of life. We talk about our personal clinical experience with patients who are at the end of life, about suffering near death and safeguarding wherever possible for patients who might be vulnerable. We finish by talking about what the future implications might be for the sustainability of our National Health Service. Before getting into our conversation it might be worth spending a moment just to outline what exactly is a assisted dying. Assisted dying is where a doctor or other healthcare practitioner prescribes medication for somebody who wishes to die. Let's call them the patient. The patient takes that prescription and gets the drugs which they know if they take them they will die. This medication is usually a combination of drugs which when taken by the patient results in them becoming comatose and then dying sometime later. So they are in effect completing suicide in this manner. So assisted dying and assisted suicide are one and the same thing. Now I understand the word suicide can be an emotive or upsetting word to use but I think it's really important to be clear and to be honest about what we're actually talking about here. Assisted dying or assisted suicide are different from euthanasia. In euthanasia the person who wishes to die, again let's call them the patient, has a combination of drugs injected into them by a doctor or other healthcare professional who knows that the injection of those drugs will result in that person's death. The bill coming before the Scottish Parliament will legalise assisted dying or assisted suicide only and will not include the legalising of euthanasia. This differs from other countries such as Belgium or Canada where both assisted dying and euthanasia are permissible in that country's law. And so now to my conversation with Robin. Robin has been a consultant in respiratory medicine for a number of years, helping people with things like chronic obstructive pulmonary disease, asthma but also many cases of lung cancer. We're going to drop into the conversation at the point where I've just asked Robin, has a patient under his care ever asked him to end their life when they know that they've perhaps been approaching the end of life? In other words, has a patient of his ever asked him to kill them? Well you've just described one of the most challenging moments that you could ever have in professional practice. I have had patients who've asked me to deliberately end their lives, probably 8, 9, 10 times. They've always had lung cancer, they've always been terminally ill and you can completely understand why they would like the last days or the last weeks of their life to be shortened. That's completely understandable. In response I've always said that's a line I cannot cross. I've always given my commitment to them that I would be with them. I think one of the fears that patients in this situation have is of being abandoned. So it's not necessarily about symptom control, although that's a critical issue, it's about being alone. It's about struggling on their own to face all the mystery of what mortality is all about. It's been very helpful for me to do these two things. One, to say I can't go there. But two, to be able to say you will never be alone. And I think that's probably the bottom line for these patients that I've encountered. Maybe they've just respected me as much as I've respected them. Maybe if they've got somebody else who was willing to take their life, they would be comfortable and happy. But by and large I've resolved the interaction with such patients. And have you found that that resolution has been satisfactory? You said it was very challenging. That's difficult for me to answer on behalf of the patients who were involved. All I can say is that we committed ourselves to what you would describe as palliative care measures to ensure that the last days of life, or the last hours of life, were not going to be distressing. Yeah, no patient of mine have ever directly asked me to kill them. But I've certainly had the experience numerous times where the family next of kin of somebody who's perhaps approaching the end of life, who's maybe dying, maybe not imminently, but certainly in the next hours, day or so, they've said to me, Dr, can you not just give them something to get them on their way to finish this? That's happened a few times. And unlike you, I think it's certainly something that's very challenging. It gets right deep into the soul of your being in a way. But what I've always done in that space, and you mentioned fear actually, I think that's the key thing for me, that there's this fear that their loved one will be suffering in some way, that that will be protracted, or it'll be terrible symptoms. But like you, I've always said that while I can't do that, I'll make sure that we focus on their comfort, that we'll make sure that they're not in pain, that they're not distressed. And I'll reassure them, maybe like you just described, that we'll be focusing on making sure that they're comfortable. And I've always found that conversation, when I've gone about it that way, has gone okay. Yes, I'm agreeing with you. I think what it highlights in terms of the next of kin, the sons, the daughters, the adult sons and daughters often, they are suffering. They're suffering for a whole variety of mixed reasons. I think to provide assurance to the family that the patient's distress is our number one priority is a key issue. Now, I'll be honest, if I were to come into your department as a dying patient, I would wonder to what extent my real needs are going to be addressed. You're working in tremendously stressed circumstances. There are people lying in corridors, there are people in resuscitation rooms, and I think one of the drivers at the moment for, you know, let's get all this over and done with on an assisted dying basis, I think one of the drivers is the challenges that there are in delivering care, particularly when it's in a setting that was never designed to do it. Yes, for sure. Sometimes you hear these sort of tales of doctors who maybe have hastened death in some way, maybe hear these stories floating about, and certainly it's mentioned in some of the proponents of this bill would say, well, this already happened anyway. Yes, I have given morphine to people at the very end of life, but it's always been to relieve pain or to relieve restlessness or whatever. It's never been with the intention of killing them. Never, and it never would be. You see, I think there is a red line here. There is a red line, and let's be truthful and accept that for some, the red line seems, from their point of view, from the family point of view in particular, that red line ought not to exist. No man is an island, and once we cross the red line for some, we're going to have to cross the red line for many, and where does that leave us? That's the nub of this issue. Yes, that's a huge concern, isn't it, that once you erode that trust between the doctor and patient, where the patient no longer can be sure that the doctor isn't going to do something, not just harmful, but might end their life, that that loss of trust would be really difficult. Well, it's very interesting. If you go back to the Hippocratic Oath, that was conceived 2,400 years ago. Why has it lasted, and why have the principles of a Hippocratic Oath stuck? And the answer is, when any patient comes into your ED, they want to be able to trust the person they're meeting. They've never met you in their lives. So what are you going to come up with as a means of assisting and helping them? And the Hippocratic Oath has put death as a treatment out of bounds. And frankly, 2,400 years later, we have, at least theoretically, the best possible palliative care we've ever had. The problem is they choosing that that's the way to go, because some people say, oh, I'm not ready for that. And families say they're not ready for that. They want cure. They don't want relief as much as they want cure. But the truth remains that palliative care in this country is the best it has ever been. And therefore, we should hold that simultaneously in our minds alongside the idea that Hippocrates put a barrier, put a wall around medical practice such that, so that you can be trusted, and I can be trusted. So it wasn't just that death wasn't going to be an option for the doctor. Also, I think, correct me if I'm wrong, the Oath was about not entering into a conversation about killing your patient. Yes, there are two key points from the Hippocratic Oath. One is, I will not set about to end the life of a patient. But secondly, and this is perhaps even the more interesting bit, I will not engage in a conversation, a negotiation, where that is the agenda. Next question. This is about ending suffering and allowing for dignity at the end of life. Why would you oppose this? The truth is, I wouldn't oppose it. I think that's our job. But curing and fixing ought not to be the priority for every patient who comes in. Yes, we should be relieving suffering. But the red line is this. If we cross into a territory where ending the life of the patient is the means of dealing with their suffering, then we have entered into very, very dangerous territory. I think I agree with you. But I think that this notion that there's proponents for assisted suicide and people who object, and there's dialect between those two camps, I don't think is entirely true. I think we absolutely need to do things differently. I think we absolutely need to focus on easing suffering. But for me, it's about changing the culture, not changing the law. The culture, just not as you described, is all about fix it, about looking for cure. I guess we can think about, let me just get this right there, another ethical thinking where we should cure sometimes, treat often, but comfort always. And I feel that we've maybe lost sight of that a bit in the 21st century. Well, we lost sight of it in the 20th century, Colin. We lost sight of it when we put cure at the pinnacle of medical success. And so that principle that you've just outlined a moment ago has been lost because we actually make heroes out of doctors who cure things, who fix things. And it's very interesting in the life of the NHS. The NHS was created in 1948, but it was only in the late 1960s that palliative care services got a look in. And I'm disappointed that palliative care as a concept as well as a service provision is actually marginal. It's still marginal. We have hospices in the leafy suburbs of Glasgow and Edinburgh. We don't have them. We don't have a palliative care ward. And here's where I get upset with my colleagues. Sometimes you'll see a referral note for palliative care, and they sort of, this is for patients who are in the ward, and you've done your best to deal with their complications of lung cancer or their severe respiratory failure due to COPD. And then when you know that you're not going to win, you sort of flip over and say, well, and you send a memo and you send for the palliative care doctors because it's no longer my business. That is wrong. That is wrong. And it's wrong. The only way we're going to change that is to recalibrate what are the priorities. I understand we're in a fix-and-ed for a whole variety of reasons. But we need to recalibrate as to what is success, what is good medicine, particularly at the front door in your setting. If we were to achieve that culture change where people aren't going to be labelled palliative to use it, which is, I know palliative medicine colleagues, that really gets their back up. If we moved away from that culture where we, irrespective of our specialty, had comfort and were at the top of our concern, that would maybe perhaps allay some of the clamour for assisted dying. Supportive care, which includes relief of symptoms, supportive care ought to have as much prominence in our hospitals as curative care, curative intent. The problem is within professional training, within just the sort of idea among the general public of what do we do in hospitals. There's a lot of work to be done in recalibrating, reconfiguring what is good in our hospitals. Okay, well let's move on. Rigid safeguards will be put in place to prevent harm to the vulnerable and avoid coercion. Why are you not reassured by these? Well, yes, I understand that Liam McArthur's proposed bill is going to include significant so-called safeguards, but to be honest they're untenable. They're untenable from a number of perspectives. There are three groups that would be eventually influenced and affected by any proposed legislation. There's the frail elderly, there's those with mental health problems and suicidal intent, and there are the disabled. Because the proposed legislation actually is untenable, there will come a time, five, ten years, fifteen years down the track, where a change in the law, as is currently being proposed, a change will have to be made. And that's what's been experienced in Canada, because initially in Canada the legislation was in favour of assisted dying for the terminally ill. And then a lobby group went to the Supreme Court in Canada and they turned that around and now the right to die is a civil right which is independent of medical prognosis. The point I'm making is that whatever Liam McArthur's intentions regarding the restricted nature of legislation in Scotland, it just doesn't make sense to believe that we can hold the line on that. And that's the reason for the progressive increase in numbers having assisted suicide in Canada. I know some people say that that wouldn't happen in Scotland, we're very different from Canada, but I don't accept that. I think we're actually really quite similar. Well, culturally we're similar. It's hard to say, but let's be quite clear. Liam McArthur's legislation would be passed by a parliament now, and no legislation passed now binds a future parliament. So in five years time or 10 years time, I think we have to take the long view. And if you look at one or two of the lobby groups who are trying to push for this, they recognise that if you get in the door, later on down the track you can expand the scope of assisted dying and assisted suicide. It's the slippery slope, yes. Okay, so we're maybe edging towards a situation where on the one hand we're going to legalise assisted suicide, but simultaneously trying in the medical profession to prevent suicide, to prevent people taking their own life. I mean, I see this about every day really in the ED where people who are, for reasons of their mental health, are harming themselves and maybe even attempting to complete suicide. Where are we going to be if we're in a situation where we've got prevention of suicide on one hand, but facilitation of suicide legalised on the other? Well, it's only a year since the Scottish Government published its, if you like, a plan for acute psychiatric services. And where they've gone in Canada is to legitimise the idea that if a patient requests suicide, and even if they have a mental health problem, that request should be honoured and respected. Now, I'm not a psychiatrist. You in your situation deal with patients with acute psychiatric problems. But if you just even think of the law as it currently stands, a psychiatrist is empowered to invoke the law in order to prevent suicide, to prevent patients with mental illness from conducting themselves in a manner which is harmful either to themselves or to other people or whatever. And I haven't got the professional expertise to comment any more significantly on this, but I'm sure you have, Calvin. I think the idea that we legitimise suicidal intent is on the horizon if we introduce this legislation. This is a big concern, isn't it? Because I know certainly that the wish to die, that suicidal thought can be very prescient and very pressing when you've just got bad news. Say you've just lost your job or you've been given a bad diagnosis, maybe, but that feeling of there's no hope can be brief, can be transient. And if we had that situation where I could offer a patient to go down the route towards assisted suicide, in that situation, do you know what, you mentioned that red line that we shouldn't cross. Again, I think it'd be very difficult to rule back from that situation. Well, I think the Canadian experience is confirming this. I mean, you may say they're extreme examples, but they wouldn't have happened if they hadn't had permissive legislation. There are one or two people in Canada with anorexia nervosa, which is a very complex psychiatric disorder. They have been assisted to die. Now they're 19 or 20 or 22 years of age. Are we honestly going to go into that territory? I think it's very worrying. Again, I've heard this notion that legalising assisted suicide would reduce the number of people committing suicide outside of that. Well, there's actually no evidence for that. It's quite the reverse. In all the countries in the West, except Switzerland, where it's a different pattern of delivering assisted suicide, but in all the major countries in the West, suicide outside of hospital and away from medical services, the figures show an increase, not a decrease, in parallel with the numbers who are having medically assisted suicide. Okay, Robin, I think we're going to need to try and draw our discussion to a close. Where do you think this is going for the future of our NHS? And what do you think maybe needs to change? Well, I don't need to describe to you the pressures in an emergency department or in acute medical or surgical wards at the moment. There are people lying in corridors for hours waiting to have their needs addressed. A significant proportion of them, 25, 30, 35 percent are in the last year of life. So the first thing to say is, if we open the door to assisted dying or assisted suicide being a legitimate management option, then I think this is going to bring pressures to bear on someone like yourself, but even more so on 26, 27, 28-year-olds, junior doctors, as to how to, if we legitimise this as a management option, i.e. you can choose to go down this path, albeit there's a waiting time, as far as I understand it. I think to have death as an option in the stressful circumstances of delivering acute medical care is going to have a profoundly demoralising effect on staff. I'd be deeply uncomfortable with that, Robin, if I'm honest. I know the bill in its current stand would mandate, pretty much, all doctors to have training in assisted dying and also to offer all options to patients, which would include assisted dying. I'm really uncomfortable with that and I think that that notion of that is very much crossing a line for me. Well, yes, my understanding is that conscientious objection is not going to be possible if Liam McArthur's medical advisory group are to be believed. I think that's a red line in itself, to be honest. But maybe we could draw a conversation to a close on this theme. I think there's a third way that we need to push for. Now, in this country, we've had palliative care services for 40 years, 45 years, and they are allegedly the best in the world, but they need to be better. I think there is a third way. I think, I must confess, I'm disturbed by the fix-it mentality that there is in our profession. As if, if you're not aiming to cure the patient, you're giving second-best medicine. And there's no way in the hospital that that mentality affects more than in the emergency department or in the acute receiving unit. I think we need a third way where resources are poured into palliative care more than anywhere else, to be honest. Because, after all, my understanding is that when it comes your time to die and it comes my time to die, in the last six months of my life, I'll consume 50 to 60 percent of the resources that I've ever asked for from the NHS. So I think the health and well-being of the NHS has to be preserved in all of this. Not just by saying we're not going to have assisted dying or we're not going to have assisted suicide. That's only one issue. It's by saying that there is a third way. And I've, you know, we've known each other for some, I've lobbied for this as best I can. We should not regard supportive care and end-of-life care as somehow or other somebody else's business. It should be as much part of your training in ED, or training for acute surgeons and acute physicians, to put that as a priority for some patients. And we should learn in our training to sort out, in dialogue with patients and in dialogue with families, who are the patients for whom supportive care or palliative care is the number one priority instead of the expensive fix-it options that are not going to achieve very much. I think we need a paradigm shift in the life of the NHS without going down the road of assisted suicide. Yeah, I couldn't agree more. That paradigm shift you describe, I think, is so necessary. The change in culture is so necessary. And I can understand the clamour for change, because I want change too. As I said earlier, I think there isn't really that much daylight between ourselves and people that want change to try and minimise some of the suffering that does occur. I think we have to accept that. It's a change that needs to be advocated and needs a voice. Sadly, the stuff that gets onto the television or onto the newspapers are the cases where those who have been trying desperately for a cure have failed to achieve that. And there may be medical faults. There may be systems faults. But as a result of that clamour, we tend to shift the emphasis onto safety and improving curative outcomes. And if we devote our energies to that in the running of the NHS, then we will continue to make supportive care, palliative care, an acceptance of human mortality. That's always going to be something that's pushed to the side and frankly, if we look 10 and 20 years down the track into the life of the NHS, it's unsustainable. The present model is unsustainable. The present model needs a shift along the lines that we're talking about just now. Yeah, so let's change the culture without changing the law. You've got it. Robin, I think that's maybe a really good place to end our conversation. Thank you, Calvin. Thank you very much. Thank you. Thank you. So, that concludes this episode. Thank you very much for listening. If you would like to find out more information on this subject, I can recommend the website of the organisation, Our Duty of Care, which can be found at ourdutyofcare.org.uk. I'd just like to finish with a quote from Catherine Mannix's excellent book, With the End in Mind. When it comes to considering the end of life, we have much to plan and little to fear. All the very best for now.