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A good death? Palliative care or assisted dying?

By Terry Maguire - 06th May 2024

assisted dying

We currently administer drugs to patients that we believe alleviates their suffering when, in fact, what we are doing is killing them, writes Terry Maguire

Esther Rantzen, the television celebrity, was recently diagnosed with terminal lung cancer. A lifelong campaigner – she gave the UK its wake-up call on benzodiazepine addiction in the 1980s and child abuse in the 1990s – she has launched a campaign in support of legalised euthanasia.

In this campaign she has strong political support. Sir Keir Stamer, the Labour politician and likely next British prime minister, is a staunch advocate. When last debated and voted on in the UK parliament in 2015 Stamer was vocally supportive and voted for assisted dying. That time the vote was lost
330 against, 110 for. Commentators, quoting recent opinion polls, suggest that the UK public are largely in favour and legislators are behind the curve.

In February 2020, my 88-year-old mother went into hospital with a suspected stroke. During her short stay my sister, who has power of attorney, was asked to sign a Do Not Resuscitate (DNR) order, which she did and with my mother’s agreement. Thankfully the stroke was minor and mother was soon home with an excellent package of care as her independent living had come to an end. Then Covid-19 struck hard and we were all locked down. Over the next two years mother managed to avoid catching the virus and remains hale and hearty in her 92nd year.

Others of her age group were less fortunate, especially those residing in care homes where in the spring of 2020, the virus flourished accounting for 40 per cent of all the UK deaths in the first wave of the disease. Care home deaths are a focus of concern at Britain’s Covid-19 Inquiry since government policy effectively cleared hospitals of older patients, placing them, without proper testing, into these homes.

Risks and choices

Age is the main risk factor for serious outcomes from Covid-19. Those over 80 years who became infected were much more likely to suffer severe respiratory symptoms and die. This was a new virus and we had little by way of treatments in the spring of 2020. It would be the summer of that year before dexamethasone was identified as an effective treatment for those who suffered the cytokine storm common in serious respiratory illness.

Access to ventilation was restricted by availability and hospital doctors were forced to decide who would be admitted for treatment and who would be left outside to the ravages of the disease. Largely they chose younger patients.

As a result, there were many very ill elderly patients living in residential accommodation with very few treatment options. A protocol was put in place for these patients. First, all patients or their relatives were asked to sign a DNR agreement. Then, when seriously ill from the virus, they were given palliative care using benzodiazepines and opioids. It was NICE guideline 142, also known as the Liverpool Pathway.

The conspiracists have latched on to this and, in their more extreme utterances, are suggesting that, in the spring of 2020 Britain’s government oversaw the culling of many of its elderly citizens. There are few facts and there will need to be a thorough investigation; these accusations need to be addressed.

There was a large increase in prescriptions for midazolam and morphine in April 2020 mostly for use
in community care. A year before in April 2019 for comparison (and the month before March 2020), there were approximately 17,500 prescriptions for midazolam injections. In April 2020 there were 35,582. These figures come from the English prescription data sets but are similar to that in Northern Ireland.

Injectable midazolam and opioids were more commonly administered via a syringe driver as treatment and management of the more severely ill patients. Their main symptoms were agitation and breathlessness. There are no available data on the numbers of patients treated or the treatment regimens used. Anecdotal reports provided by documentary filmmaker Jacqui Deevoy, in her film titled somewhat sensationally A Good Death? The Midazolam Murders, claims that many patients were put onto higher- than-expected doses of midazolam and morphine. Some were started on 5mg/24 hours of each drug where a starting dose for mild sedation was much lower than this. This is not true and the dose for midazolam would be 5mg-10mg over 24 hours in a syringe driver for palliative care. What seems to be clear is that doctors and nurses treating these patients were applying a palliative care approach as they assumed they were going to die. That, if it was the case, was a dangerous assumption as this was
not COPD or terminal cancer, this was a serious respiratory infection – but was death inevitable?

Worsening condition

The choice of these drugs to manage the extreme respiratory symptoms of Covid-19 was, of course, likely to worsen the condition. A combination of midazolam with morphine will significantly suppress respiration. Indeed, many drug deaths in younger people are as a result of a combination of drugs including benzodiazepines and opioids.

In the case of Covid treatment, this is termed the Paradoxical Effect, where the side effects of the drugs cause the nurse or doctor to increase the dose based on worsening of symptoms when, in fact, the worsening of symptoms are a direct result of the drug. Only lowering the dose will improve the symptoms.

What is factual is that in April 2020 in the UK, there was a huge increase in deaths in elderly patients living in residential care and there was a huge increase in midazolam and morphine use in syringe drivers. What is not factual is that this correlation proves causation. These deaths are registered on death certificates as Covid-19 deaths; they were not registered as iatrogenic deaths.

Palliative care has always walked a fine line between caring for patients at the end of life and mercy killing. That fine line has been controversial and will be focused on by those now attempting to get assisted dying onto the British statute books.

Esther Rantzen has threatened to die at Dignitas in Switzerland if she cannot access assisted dying in the UK when she needs it. Assisted dying is now available in many countries across the globe often using the very medicines which were used controversially to manage elderly patients with Covid-19.

In the US state of Oregon, which allows assisted dying, they have stuck to the original remit: With six months to live from a terminal disease a patient can opt for assisted dying. What is concerning
to most opponents of assisted dying is that, in some countries, there has been mission creep. In Quebec, Canada, for example the remit initially was for those whose death was ‘reasonably foreseeable’ from a terminal illness, but has now been extended to people with chronic conditions. In Belgium, changes to the original law have allowed a patient with PTSD, due to her experience of a suicide bomb attack at Brussels airport, to end her life. This patient saw her friends brutally and fatally mutilated but she was not physically hurt. There is a chilling irony here.

In Belgium, changes to the original law have allowed a patient with PTSD, due to her experience of a suicide bomb attack at Brussels airport, to end her life

There is in my view no clear or absolute line between palliative care and assisted dying. We currently administer drugs to patients that we believe alleviates their suffering when, in fact, what we are doing is killing them. Was the treatment of very ill elderly patients in April 2020 anything but assisted dying by another name? I hope that Esther Rantzen has a good death when it happens and I also do not want to see my mother suffer when the end is inevitable in the coming years, and therefore I won’t mind or complain if they call it palliative care or assisted dying.

Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.






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