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Should GPs play a role in assisting a patient's death?

The BMA should follow the Royal College of Nursing and end its opposition to legally assisted dying, says Dr Colin Lennon. But Dr Tony Calland argues GPs should take into account patients' views in offering treatment and pain relief, but helping them die would be a betrayal of trust

The BMA should follow the Royal College of Nursing and end its opposition to legally assisted dying, says Dr Colin Lennon. But Dr Tony Calland argues GPs should take into account patients' views in offering treatment and pain relief, but helping them die would be a betrayal of trust

Not only is it appropriate for a GP to be involved in a patient's wish to die, but GPs should be leading the debate on this issue. We are encouraged as a profession to involve ourselves in the lives of our patients, supporting them to eat healthily, exercise more, stop smoking and drink less. But when it comes to the end of a patient's life we abandon them to chance.

We are encouraged to discuss with patients where they would like to spend their final days. But what patients who are suffering really want is some control over when and how - as well as where.

If a terminally ill patient wants to hasten their death, they have three options.

Those who can afford it and are physically able can travel to Switzerland and choose an assisted death in unfamiliar surroundings in a largely unregulated and unsafeguarded environment. This is unacceptable.

Another option is suicide. This is not illegal in the UK and under new Director of Public Prosecutions guidelines those who assist in the suicide of a close relative or friend who is terminally or chronically ill, mentally competent and asks for help are unlikely to be prosecuted. But these suicide attempts are often violent and don't always succeed, leaving the patient in a worse state. This is also unacceptable.

The third option is suffering for as long as the illness takes to kill the patient. If this is against their wishes it too is unacceptable.

Patients do have the choice to make an advance decision to refuse treatment at the end of life, under certain circumstances, which can help to make option three slightly more bearable, but choices remain limited.

For many people, palliative care, if they can gain access to it, can relieve much of the suffering at the end of their lives. We certainly need better access so that it is an option for all people who are dying.

However, even if universal access were realised there would still be a need for legalised assisted dying. Palliative care does not alleviate the constant suffering and indignity that some people endure. And it is for this small but significant minority that assisted dying should be available.

Earlier this year the Royal College of Nursing launched a consultation on assisted dying, and commendably changed its position from opposed to neutral in line with its members' views (a majority were actually in favour of legalising assisted dying). I urge the BMA to do the same.

The BMA has an opposed policy position based on a decision made by a few members at an annual meeting. For a representative body this is appalling.

Some members of the BMA will not support a change in the law to allow assisted dying, and some doctors, even with a change in the law, would not want to be involved in assisting a patient's death.

I fully support a doctor's choice not to be involved in a patient's assisted death - there are enough doctors who do support this to make an assisted dying law workable in the UK.

Terminally ill, mentally competent patients, suffering at the end of their lives, should to be allowed access to life-ending medication, to be taken at a time of their choosing, within strict legal safeguards. And doctors should be leading the call to ensure this happens.

Dr Colin Lennon is a GP in Melksham, Wiltshire, and a supporter of Dignity in Dying

The simple and lawful answer to this question is no.

The law is clear in stating that it is an offence to knowingly and deliberately assist a person to commit suicide or to die, even when they are competent to make such a request and when their pleas may seem reasonable to any compassionate person.

Even if there is a change in the law, my view, and that of the BMA, is clear. I do not believe that doctors should participate in assisted suicide or euthanasia.

The doctor-patient relationship is built on trust. If doctors were seen as a group to be participating in 'premature' patient deaths that trust would be eroded. Hippocrates states 'I will give no deadly medicine to anyone if asked, nor suggest any such counsel'. The issue is not new and there is no need to change 2,500 years of successful practice now.

As GPs we are frequently looking after patients at the end of their lives. Many GPs feel that giving good palliative care to their patients, allowing them to die with dignity at home, is one of the most important aspects of modern general practice. It is very important that doctors understand the ethical and legal issues surrounding this aspect of care so that they are not unwittingly laying themselves open to challenge after the patient has died.

Doctors need to understand the law, the GMC guidance on end-of-life matters, the pharmacological properties of opiates, their use and the recognised pathway protocols in common use.

It is important to consider the dose regime for a patient and the timing of instigating a treatment pathway. Also, for some patients, it is important to consider whether to cease treatment and when. Should antibiotics be used for the terminally ill patient who is developing a chest infection? Should the patient be resuscitated? Should artificial hydration and nutrition be started or withdrawn?

When considering the answers to these questions, one has to start from the position that any intervention taken knowingly with the direct intention to end the patient's life is illegal and could lead to criminal prosecution.

Some will argue that there is no difference between controlling a patient's discomfort with pain relief, knowing that the medication might shorten life, and deliberately giving enough opiates to end the patient's life abruptly. But there is a difference - and the difference is around direct intention.

As all doctors will know, there comes a point in a patient's life when they are going to die within a matter of hours or days. It is perfectly reasonable not to resuscitate a person in the final stages of life because the chances of a successful outcome are minimal, and also because meaningful recovery is impossible and any resuscitation would be futile and arguably degrading. Similarly, starting a patient on opiate pain relief and maybe other sedative drugs is legitimate if treating their pain and agitation and will allow them over time to die naturally, peacefully and with dignity.

Sometimes patients will request that doctors end their lives. One has to deal with such requests respectfully - not to act on them, but to allay the fears that many patients experience. Again one has to ask questions. Is more support available? What more can be done to ease this patient's pain or distress?

When treating the dying in today's world it is essential to find out what the patient's wishes are. Doctors have to be aware of any advance directive which may refuse treatment. If this document is legally valid it must be respected as it is legally binding.

But respecting a patient's wishes by not giving them treatment they do not want is one thing. Assisting a patient's death is quite another, and not something I believe a GP should do.

Dr Tony Calland is chair of the BMA medical ethics committee and a former GP

yes no Should GPs play a role in assisting a patient's death?

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