Helen Salisbury: The assisted dying bill must be accompanied by a funding boost for palliative care
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2696 (Published 03 December 2024) Cite this as: BMJ 2024;387:q2696
- Helen Salisbury, GP
- helen.salisbury{at}phc.ox.ac.uk
Follow Helen on Bluesky @helensalisbury.bsky.social
One effect of last week’s parliamentary debate and vote to change the law on assisted dying is that more people are talking about death, which isn’t a common or comfortable topic of conversation here in the UK. In hospitals and GP surgeries the focus is generally on preserving life, and the topic of death is surprisingly rarely tackled head on. Hospices are an exception: their staff have had practice and are comfortable talking about death as much or as little as each patient wishes.
Many patients don’t want to discuss death. I remember one complaining to me about his oncologist: “Why does he have to check at every appointment that I understand that I’m dying?” he asked. “I do know, but I really don’t want to be constantly reminded.” Others, I suspect, would like to discuss death, and to ask what exactly will happen, but find it difficult to broach the subject. And as a doctor it can be tricky to raise the matter, unless you’ve been invited to or the end is clearly imminent. Some previous, rather clumsy, centrally mandated attempts to encourage more discussions around end-of-life care under the guise of “advance care planning” resulted in upset, with elderly-but-healthy patients asking why their GP wanted to discuss their resuscitation status and wondering if we knew something about their health that they didn’t.
As patients weigh up their options—especially if the bill becomes law—I anticipate more conversations with patients nearing the end of life. I hope to see a specialist service to which people who are considering assisted dying can be referred, staffed by doctors who can explore reasons and give explanations. But before we get to that stage, patients will have questions for GPs—such as “What medicine will they use?” and “How long will the whole process take?”—and I don’t yet have the answers. I hope that any such service will be well organised and funded, with its work clearly explained to the public and to other doctors.
Outdated structures
In my area we’re lucky to have an excellent and accessible palliative care service, but even the best treatment in the world can’t stop the psychological pain some patients feel at the progressive lack of control of bodily functions, the total dependence on others, and a loss of dignity. An end-of-life choice should be between carrying on with the very best symptom control that medical science can offer or dying at a time of your own choosing. The fear among many who oppose assisted dying is that, as this expert palliative care isn’t available to all, people will choose death to escape symptoms that could have been remediated.
The new law, if it passes all its stages in parliament, should result in a boost to the funding and staffing of palliative care, so that we can be certain that the people choosing to bring their deaths forward are not doing so out of fear of physical pain. A first step would be to end the bizarre and outdated structures that result in the vast majority of hospice funding coming from charities, with money raised by sponsored skydives and bake sales rather than provided by the NHS.
Opponents of the bill fear that it will have the opposite effect, driving investment away from palliative care, as assisted dying could be seen as an easier and cheaper option. In the bill’s committee stages MPs will scrutinise the safeguards designed to ensure that this won’t happen. Whatever the outcome, it will still be a long time before my terminally ill patients have an opportunity to exercise choice over the manner and timing of their death.
Footnotes
Competing interests: See www.bmj.com/about-bmj/freelance-contributors
Provenance and peer review: Commissioned; not externally peer reviewed.