Black cloud over GP palliative care
Harold Shipman's murders ensured GPs' palliative care practice would forever remain under a spotlight.
By Rob Finch
Now the case of Dr Howard Martin has brought the subject back into the glare of publicity.
Dr Martin was cleared in December of all three charges of murdering elderly chronically-ill patients and, as he himself proclaimed as he left court, is no Harold Shipman. But that has not stopped serious questions being raised about his practise.
The GMC is considering Dr Martin's conduct and the coroner is also investigating a further 12 deaths linked with the GP's care.
During his trial the court heard Dr Martin had given patients 60mg doses of morphine and diamorphine. Palliative care experts gave evidence that this was between six and 12 times the recommended dose and should only be given minutes before death.
But they added that procedures in community GP practice were behind the times and dosing was 'not an exact science'.
So what is the reality? Is GP practice too variable? Or are isolated high-profile incidents overshadowing widespread good practice?
One thing that is clear is that GPs are worried about the apparently growing legal dangers that come with palliative care and the prescribing of opiates. And a significant number of GPs are practising more cautiously as a result.
No GP wants to endure the fate that befell Dr Martin or Dr Paul Davis, who endured a nine-week ordeal a year ago after being arrested on suspicion of murdering a patient and still faces a GMC fitness to practise hearing despite never being charged by police.
As Dr Davis recounted to Pulse (December 17), he now practises more defensively, using witnesses and specialist advice when he visits seriously-ill elderly patients, and rarely prescribes opiates even though, he admits, this may be to the detriment of patients.
Such caution is not limited to GPs like Dr Davis who have had their practice questioned. Others say dealing with opiates in the post-Shipman era brings a fear of potential repercussions and that this impacts on the way they approach such cases.
Dr David Wrigley, a member of the GPC registrars subcommittee and a GP in Carnforth, Lancashire, says the potential consequences of any untoward events are in his mind when providing palliative care particularly where opiate doses could hasten death.
He says: 'I think it's going to be on your mind and you consider what dose you're giving when it gets to that. It's going to be a black cloud over the profession for years to come.'
Since the Shipman case, he adds, patients have also become more jumpy and some have declined opiates.
Dr Krishna Korlipara, a GP in Bolton, agrees increased scrutiny of opiate prescribing causes worry among even experienced GPs. But he says that does not change the core principle that GPs have to do what they think is right to relieve pain appropriately and has not changed his practice.
The effects of morphine are well known so there should be few concerns, even though it is a drug of 'last resort', Dr Korlipara believes.
He says: 'Doctors have to make the decision that the dose may shorten life, but that's not why we give the drug it's to remove pain. If I had to testify I'm supremely confident I could justify what I had done.'
GPs also dispute the assertion made in the trial of Dr Martin that practice varies widely from doctor to doctor and is often out of step with good practice.
Dr Murray Freeman, GP cancer lead for Birkenhead and Wallasey PCT, says GPs should not be put off by 'isolated cases' involving the use of opiates.
'As long as you stick to the guidelines you'll be OK,' he says.
'Palliative care is central to what we do and opiates are one of the range of options.'
Dr Tony Brzezicki, chair of the south-west London cancer network and a GP in Croydon, Surrey, says greater scrutiny of GPs is a 'necessary evil'. But he warns that because of their concerns over potential problems, fewer GPs routinely carry controlled drugs. This could jeopardise good care and lead to a 'disaster' of deskilled GPs, he adds.
Consultant specialists are adamant that GPs should have few worries about prescribing opiates when circumstances demand providing they have asked and answered the correct questions about the case.
Dr Irene Carey, consultant in palliative care at Guy's and St Thomas' Hospital, says: 'As long as an appropriate assessment has been made and an appropriate dose of an appropriate medication chosen, clear sensitive communication with all involved almost invariably eliminates any problems.'
The worst course of action, she adds, is for a dying patient to get inadequate pain relief because a doctor fears their actions might be questioned.
This appears to be the crux of the issue for GPs. The vast majority seem comfortable continuing to provide palliative care and to prescribe opiates when the situation demands. And none would disagree with Dr Carey's statement. But for as long as there is a perception that police or patients are looking to find fault and to find the next Shipman there will be nervousness among doctors.
Advice on opiate prescribing
- Reassure patients and relatives about the place of the drugs and their value in treatment
- Comply with the legal requirements for carrying and supplying controlled drugs (www.npc.co.uk/publications/Controlled_Drugs_December_2005.pdf)
- When prescribing follow good clinical practice set out in the BNF, remembering co-morbidity and co-prescribing
- If departing from recommendations make it clear to the patient and record in contemporaneous notes
- Speak openly to the patient and, subject to consent, to relatives about what and why you are prescribing
- In case of anxiety by patients or relatives, a second opinion is invaluable