Palliative Care Bill [HL]

My Lords, I, too, congratulate the noble Baroness on introducing this Bill. I also express my deep sympathy for my noble friend Lady Gardner in her loss; I was deeply moved by her courageous speech. I declare an interest as president of the Mildmay centre in east London. I was involved in setting up this first hospice in Europe for people dying of AIDS. During the Select Committee chaired by my noble and learned friend Lord Mackay of Clashfern, we had a very useful contribution from Help the Hospices, which stated that, "““experience of … pain control is radically different from the promise of pain control, and cessation of pain almost unimaginable if symptom control has been poor. On this view, patients seeking assistance to die without having experienced good symptom control could not be deemed fully informed””." It is clear that some people have not grasped the important fact that experience of pain control is radically different from the promise of pain control. When one reads some of the speeches on previous debates on the hospice movement, one realises that there are serious misunderstandings about the nature of palliative care. The noble Baroness, Lady Finlay, drew attention to NICE’s definition: "““Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social, spiritual support is paramount””." I was pleased to see that incorporated in Clause 7 but sad that in our previous debate on palliative care, on 31 January, the Bill was criticised for including, "““psychological, social and spiritual help””," which NICE said was paramount. The critic described the inclusion in the Bill as ““mission creep””. The question was asked: how would NHS performance managers measure the efficacy of spiritual intervention? How indeed? As other noble Lords have asked, are we saying that, because we cannot measure something precisely, it cannot be allowed to exist? I hope not. It sounds rather like the language of accountants, who know the cost of everything and the value of nothing. That was stressed by my noble friend Lord Cavendish of Furness, the right reverend Prelate the Bishop of St Albans and the noble Lord, Lord Alton of Liverpool. NICE went on to say: "““Palliative care is part of an overall supportive care, which anyone facing a life-threatening or long-term illness will need at some time””." Palliative care is often seen as simply offering pain control and symptom control, but if offers a great deal of psychological support in helping people to come to terms with what may have been potentially a devastating diagnosis or piece of news at the end of a process of treatment. In the debate on 31 January it was implied that there were patients who did not want palliative care, which includes relief of nausea, vomiting, respiratory distress, pain, intolerable itching, anxiety, insomnia and many other symptoms. Where are the people who want to suffer those symptoms without relief? Perhaps the misunderstanding derives from another statement in the debate that opiate medication caused drowsiness and dry mouth and made patients befuddled, and that some patients forgo pain relief to avoid that. They choose to be alert at the cost of considerable suffering. Good palliative care avoids the need to make that choice. Modern drugs in small, precise doses relieve symptoms without knocking the patient out. It was stated that breathlessness, profound wasting, skin breakdown and choking are difficult to relieve, but those are the very symptoms that palliative care concentrates on preventing and relieving. How is that accomplished? As the noble Baroness, Lady Emerton, emphasised, such symptoms are prevented by good—excellent—nursing care. When a patient is dying he is susceptible to thrush in the mouth, called candida because it is a bright white colour. It is easily treated. Dry mouth from drugs, or because the secretions tend to dry up when the circulation of the blood is inadequate, can be effectively managed with good mouth care. Anyone who goes to bed for a week—I am sure that all noble Lords have experienced this—tends to develop painful areas. There are six areas to be precise: heels, elbows and the sacral area. If regular attention is not paid to those areas, they can ulcerate and produce a very uncomfortable and painful bedsore. In the good old days, if a patient developed a bedsore the attending nurse had to report to the matron—that was when we had them, and how much we miss them. Pressure sores are a pointer to poor nursing care. They are not an inevitable accompaniment of terminal illness. People may have a mistaken view of palliative care because their views are coloured by what happened several decades ago, when pain and other symptoms were poorly relieved by inappropriate doses of morphine, which were only given when the pain had come back with a vengeance. The exhausted patient tended to lapse into semi-coma and then resurface whenever pain returned, only to be greeted by another injection of morphine. As has been mentioned, the speaker on ““Thought for the Day”” only this morning, who clearly had little knowledge of modern medicine, stated that doctors commonly give patients in pain massive doses of morphine to end their lives. That is outdated medicine of a bygone age. The noble Lord, Lord Lester of Herne Hill, raised the doctrine of double effect, which has troubled him for some time. I am grateful to him for confirming that Mr Justice Devlin described double effect in the trial of Dr Bodkin Adams. With all due respect to the learned judge, who eventually became a Member of your Lordships’ House, the term ““double effect”” is most unhelpful. All treatments have a double effect. Penicillin can be given to cure an infection, but it can and occasionally does kill the patient. Dr Bodkin Adams was accused of deliberately killing a patient at the end of her life with a large dose of morphine. The jury took exactly 45 minutes to reach their verdict of ““not guilty””, and rightly so. The chief prosecution witness was asked by the brilliant barrister for the defence whether he could say what would be the effect of giving this large dose of morphine to the patient. The witness said, ““Given with intent to kill””. The barrister hesitated, there was a long legal pause and shuffling of papers, and asked, ““Would you like to reconsider that statement?””. ““No, quite definitely given with intent to kill””. There followed a further shuffling of papers and another long legal pause, and the barrister then said, ““Would it interest you to know that the patient received a similar dose three months before, without it killing them?””. It later came to light that this expert witness had given a similar dose to a private patient six months earlier. Much smaller doses are used nowadays, together with more effective drugs. It is important to emphasise that the dose required to relieve pain is a fraction of the dose required to kill. That, after all, is the definition of a good drug; we call it the therapeutic index. Some have accused doctors of hypocrisy in saying that they are giving morphine to relieve pain when they really know that they will kill the patient. That is quite a false accusation. If, however, the doctor was giving alcohol to relieve pain, that would be hypocrisy; the dose required to relieve pain is the same as that required to kill. So we can bury this confusing and unhelpful doctrine of the double effect. As a suggestion, would those noble Lords who harbour doubts about the effectiveness of the hospice movement like to spend a day in a hospice, shadowing staff to see what goes on at first hand? I am sure that they will be surprised at the sensitivity of the care and the serenity of the place, let alone at the high morale and the warmth. That atmosphere is greatly appreciated by patients and families. Noble Lords might find it strange that those who work in an environment of imminent death enjoy their work and are fulfilled as they realise the true value of their vocation. I wish the Bill well and congratulate the noble Baroness, Lady Finlay, on this excellent piece of work.