The real test of society is how it deals with dying people

Author
Robert Becker, Macmillan senior lecturer in palliative care, Faculty of Health, Staffordshire University

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There are few subjects as emotive and contentious as the arguments surrounding who the NHS can afford to treat. The recent decision by NICE to extend the financial threshold at which a small number of patients with cancer will receive potentially life-extending and hopefully life-enhancing drugs is sure to resurrect the complex arguments in this area. It's time to take stock of the bigger picture and how this decision may impact on nurses' clinical practice.

Like it or not all health care has to be paid for and in the UK that happens via the taxpayer. There is a finite budget and priorities have to be made. In the UK over 500,000 people die each year and unfortunately many still die in none too ideal circumstances. The real test of any civilised society is not only how it deals with the funding and promotion of good health for its citizens, but also how it funds and deals with those who are dying.

Unfortunately NICE does not have a good record for humanitarian responses in its decision-making. In fairness that is not in its remit and in many regards it is damned if it does, by politicians and economists counting the pennies; and damned if it doesn't, by both the public and healthcare professionals who feel that it simply does not care.

For nurses, clinical practice and our code of conduct is driven by the principles of duty and obligations. NICE is driven by a utilitarian approach that tries to achieve the greatest good for the greatest number of people and that does not depend on either duty or principle.

It's about time that NICE learnt that the two are not mutually exclusive and I would like to think that this new decision indicates that it is now acknowledging this. However, the sceptic (or is that cynic) in me remains cautious. It would seem on the face of it that NICE has indeed responded with a more humane decision.

In November 2008 this new proposal went out for public consultation and the responses were unequivocal. 'Treatment should be given regardless of cost if no alternative is available. The proposals support the wider societal values of humanity and compassion' (NICE, 2008).

It is not so much the extra quantity of life afforded to these patients that is of significance to nurses, but the quality of that life. The focus on medicines alone is only part of the issue here. It is nurses who will be the primary care providers for this group of people and nurses who will find themselves using their skills to balance the people's pain and symptom management with good psychological and spiritual support.

Inevitably, therefore, it is nurses who will be the ones fielding the difficult ethical questions over who is deserving of these drugs and why the person down the road who has long-term lung disease cannot obtain the support she needs, simply because she doesn't have cancer. Our finite resources mean that the money for this new approach from NICE will need to be found from somewhere. There are no easy answers and nurses will need all their listening and attending skills honed to perfection at such times.

Reference

NICE (2008) Appraising Treatments Which May Extend Life, At the End of Life . London: NICE.

For a case study on resuscitation in end-of-life care, see p19

• Related article on NursingTimes.net: Expanding the remit of palliative care

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