A Good Death

Everyone has an opinion about the Euthanasia Bill.

For most people with an opinion, the number of times they will be affected by the bill in their lifetime could be counted on one hand. For me, in my current placement, it would affect me daily. I regularly deal with frail, elderly people with terminal diseases. On the whole, they are managed very well, and are often discharged to die at home with dignity, surrounded by their families, supported in the community.

However, there are regularly people who slowly waste away in side rooms in hospitals, with their poor families spending hours, days, weeks in a horrible limbo awaiting their inevitable, but strangely reticent, death. Desmond Tutu has recently been quoted as saying that a “dignified death is our right”. There is nothing dignified about a prolonged dying process. There is nothing sacred about the last few days spent rattling, gurgling and unable to communicate.

I recently had a patient who expressed the wish to die constantly. He was an elderly gentleman who had lived an incredibly full life and was immeasurably frustrated at his current inability to do all the things he wanted to. He was not coping at home, but refused help, and was repeatedly hospitalised due to falls or chest infections. He refused antibiotics for his third pneumonia, and eventually wasted away after a long period of discomfort in a side room in hospital.

Of course, the situation will invariably be more complex than this. The proposed Bill would allow doctors to provide fatal medication to people judged to have less than 6 months to live. As with everything in medicine, there are no certainties. There is new information emerging all the time; scans can be reported poorly and treatments can work better or worse than expected. Estimating survival time is my least favourite part of my current job in Geriatrics. You will inevitably be proven wrong by a patient living months rather than weeks or hours rather than days. People towards the end of life fluctuate regularly with regards to wishes and needs. They are scared. They are frustrated. They are dying. These are difficult situations. But just because something requires thought, and safeguarding, does not mean it is not worth implementing.

I am not suggesting that we approach terminal illness in any way differently with regards to our palliative care input, and our social support systems. These systems are, by and large, incredible, and hugely beneficial to both the patients and their families. However, I think that we have a right to make decisions about our own lives. We are already able to refuse life-prolonging treatments, we can say no to life saving procedures. However, we are unable to actively end our own lives, and that is contrary to our right to autonomy as human beings.

Bishop Egan is calling for group prayers across the UK prior to the discussion in the House of Lords. Apparently, legalising euthanasia would mark the “catastrophic collapse” of the respect for life. Unsurprisingly, I disagree.

As always, religious arguments that hinge on our lives not being our own to dispose of baffle and vaguely amuse me. The argument centres on the fact that God knows what is best for us; life is a gift from God and we should appreciate it. If we take this viewpoint to its full force then where do we draw the line with medical treatments? It is bizarre to me that it is deemed acceptable to do things to prolong our “God given” life, and yet not to shorten it. Surely if God should choose when we die then neither of these things are acceptable. Surely there is an argument that if God has given us the knowledge and ability to heal people, He would be in favour of us using that knowledge to hasten a hideously prolonged wasting away of a previously fiercely independent octogenarian with incurable metastatic disease.

Not all opposition for legalising euthanasia stems from religion. There are people who worry that allowing people the option of ending their lives will lead to a lack of respect for those who don’t, a pressure on the elderly to end their lives prematurely, a reduction in the importance of good palliative care and end of life management.

Safeguarded correctly, no one is going to be forced to die early. Just because euthanasia might be legalised does not mean it will be imposed on the whole population. If you don’t agree with it, then don’t choose it. But people should have the right to decide what happens to them in their final days, a right to die comfortably, quickly, and at a time of their choosing.

Aneurin Bevan is my hero

The NHS gets a bad press. 

As an organisation founded in 1948, it is no wonder that it is struggling to keep up with the growing demands and expectations of an ageing population. The fundamental principle of a free at point of service healthcare system for all, is something that I am immensely proud to be a part of. It is consistently portrayed as a decaying and inefficient system, with no option other than privatisation viable to sustain it. 

I think this is a mistake. 

I have first hand experience of the dedication of NHS staff to ensuring effective and timely management for patients regardless of their social status. With privatisation will inevitably come prioritisation, and we will be in severe danger of losing the ethos of our healthcare system.

Despite the overarching belief that the NHS is an outdated model which needs renovation, England still has the best healthcare system in the world. I think it is pretty spectacular that from first presentation at A&E to diagnosis and initial management of complex diseases such as cancer and heart failure takes on average only 48 hours. And 4 of those will be spent waiting in A&E…

My colleagues and I consistently stay beyond our finishing time in order to update families about patients’ progress, or to deal with emergencies that inevitably seem to occur at 5:30 when you are crabby and tired after a long day and should have left the hospital already. There is a sense of shared responsibility, a sense of duty and an underlying pride at being able to provide the world’s best medical input for people who would be otherwise unable to afford it. Yes, there are days when the inefficiency stifles me, when I get irreparably frustrated with our lack of resources and the dissatisfaction of patients and staff alike, but on these days I try to take a step back and remember the principles that our system is based on, and the ethos we are working for, and then the shortcomings don’t seem to matter as much.

The NHS has become a political model, and as such it is not left alone long enough to gain level footing. Every new government has to have a different plan for saving the NHS, and as such none of them are given time to work. Instead of giving up on it, we need to accept that as an organisation it is always going to require more funding, it is always going to be inefficient (because how can you legitimately price health?)..instead of lamenting this, we should be proud of it. There are few better things to spend our money on than health provision. We should be praising NHS staff, and supporting them, bankrolling them, celebrating them. We still have a reason to be proud of our healthcare system. We should not condemn it just yet. 

Blame Culture

One of the biggest challenges facing doctors is the difficulty of balancing the need for accountability and avoiding the often quoted “blame culture”. It is a semi catch-22 situation, in that you cannot victimise people for making the wrong decisions, as we are all human and our choices are not perfect, however, you cannot continually let people make mistakes which endanger the lives of patients with no consequences. 

Medicine is an interesting arena where, more than any other profession, we have been indoctrinated to cover up and ignore our mistakes. The very fact that there are forums emerging, urging us to speak up when things are handled badly, and encouraging us to believe that there is nothing to fear from raising concerns, shows us that as professionals we are very bad at dealing with clinical errors. 

There is a belief in the general population that medical professionals should always know what to do, and should consistently make the right choices in often very difficult situations. It leaves us, as doctors, in a weird limbo between a God complex, and feeling constantly unable to live up to the excruciatingly high standards that our patients expect from us. 

At medical school, we are taught to be confident, competent, and consistent. We are taught not to show weakness, not to show doubt, to be the best. As a result, we hide our areas of inexperience, instead of asking for help to improve them. 

Of course, we all know that doctors are not infallible, the media is full of glaring examples of our errors. We are not allowed to quietly make mistakes, hope that no one notices and carry on with our lives. Our mistakes are aired at monthly morbidity and mortality meetings, they are dissected by patient’s relatives, discussed at Incident panels. They are, at worst, held up in courts of law and splashed across tabloids. This is as it should be; we are not innocent victims – we chose this profession and we did it because we wanted to improve people’s quality of life. We knew going into it that our mistakes are inescapably more consequential than they would be if we misbalanced a client’s account or lost our company money. 

However, our mistakes are inevitable. And the result of holding them up for the world to see is an inescapable inertia, where people are reticent to suggest or initiate anything that they are not 100% convinced about. A work day spent second guessing yourself and never actually getting round to doing your job.

I have experienced this first hand – mistakes made on a previous job have led to me berating myself so fiercely that I have lost all confidence in my ability as a doctor. Take this feeling and multiply it exponentially, and you come close to the effect of media scrutiny, patient expectations and the pressure placed on us by the NHS as a whole to never screw up.

This leaves us at an impass. We need meetings to dissect mistakes and ensure that they are not repeated. We desperately need tailored training opportunities, targeted at our personal areas of weakness, instead of generic programs that are irrelevant to most of us. We need forums in which we can admit to our errors without fear of looking stupid. 

The crux of the matter is that doctors are flawed, often overworked, overwrought, short-tempered human beings trying to do a job which requires a robotic attention to detail and superhuman diagnostic powers. The expectation placed on us as individuals is unrealistic and unsustainable. The first step towards rectifying the disparity between our idealistic view of healthcare provision and the reality is to recognise that we need help. That there will always be that 4am incorrect dosing or the split second indecision about management. Being a good doctor does not mean you never make mistakes, it means that you don’t make the same one twice. Through discussion of clinical errors we get to learn from not just our own mistakes, but also those of others, and this is no bad thing. 

This rant is, at its heart, a plea for understanding from both the medical community and the general public as a whole. Medical professionals need to exist in a culture where they are not victimised for their errors. A culture where they can feel free to admit mistakes and are presented with the opportunity to learn from them. And then if they don’t, then they should be publically flayed.