Dying patients denied pain relief because of legal fears
Dying patients are being denied adequate medication to control symptoms and relive pain because nurses fear prosecution for assisting suicide, a Nursing Times survey has found.
More than one in 10 of the 2,311 respondents to the online survey of nurses said they had restricted a patient’s medication despite that exacerbating symptoms as they were concerned about being prosecuted.
The respondents acknowledged restricting medication left patients in more pain than necessary and prolonged their lives against their wishes.
Commenting on the survey, one nurse said: “I was worried about the authorities scrutinising the medication record with the intention of prosecuting me for over-medication, even though the dosage was ordered by a physician and necessary to relieve the patient’s pain and suffering.”
Another said increasing medication could be a difficult “balancing act”.
“Giving opiates could reduce pain but increase respiratory depression. I am acutely aware that my actions within my role could result in not being able to practice or legal proceedings.”
Senior nursing leaders said the survey finding showed a need for “urgent” action and clarification of nurses’ legal position and professional accountability.
Department of Health end of life care programme director Claire Henry told Nursing Times: “This is a disturbing finding. A competent and confident nurse should not approach pain relief with fear or trepidation.”
Queen’s Nursing Institute director Rosemary Cook said the Nursing and Midwifery Council code of conduct required nurses always to act in the patient’s best interest.
“Holding back on pain relief to the extent that pain is not controlled is clearly not in the patient’s best interest,” she said.
She said that nurses acting in the best interests of the patient and within the prescription made for that patient should not be prosecuted.
“But if the fear is there, and the anxiety has been planted, it is an urgent issue and [nurses] need to know where they stand,” she added.
In its manifesto published last year the National Council for Palliative Care called for mandatory training in palliative and end of life care for all healthcare professionals.
The council’s director of policy and parliamentary affairs Simon Chapman said better training would help remove myths and misunderstandings.
He said nurses needed to understand there is a “significant difference” between increasing drug doses in the relatively small increments required to control pain, and increasing them in such large doses that life is threatened or toxicity develops.
But one in three of the respondents to our survey said they did not understand the legal position of nurses with regards to assisted suicide.
Mr Chapman said: “It is very worrying to see this is preventing people from receiving adequate symptom control at the end of life. This is not acceptable and should be regarded as a failure of care.”
What survey respondents told us
“Doctors and nurses are scared to even think about this in case they are sued for overdosing the patient.”
“There is a tendency to under prescribe pain relief even among the palliative care team.”
“The fear of accusations of assisting/hastening someone’s death means that patients who are at the end of life are being denied a dignified, pain free death.”
“Although our hospital uses an end of life care pathway the doctors are very reluctant to initiate it for litigation fears.”
“As long as my motives are to relieve symptoms, and medications are administered regularly and increased gradually, I am justified in giving potentially lethal doses of medications to palliative patients. However many of my colleagues and doctors act too cautiously leaving patients in unnecessary pain, discomfort or unrest.”
“In some patients it is difficult to titrate medication to relieve symptoms effectively and not be concerned about the possibility of this accelerating the cessation of life.”
Mark Shaw, a healthcare specialist at law firm Hempsons, said the crucial fact in relation to the law was the intention with which the drug was prescribed and administered.
“If a drug has been prescribed by a doctor - and the intention is clear that it is to relieve symptoms and pain - and [the nurse] is following the doctor’s prescription by administering that medication, I don’t see any risk to the nurse,” he said.
But comments from the survey revealed nurses felt they could not always administer enough medication to control a patient’s symptoms because doctors were not prescribing adequate amounts for fear of being prosecuted themselves.
However, British Medical Association head of science and ethics Vivienne Nathanson said most doctors understood the concept of “double effect”.
“If you give a dose that might shorten life, because you are giving it to get rid of pain, that is a side effect. It is not the desired effect, so it is not criminal or unacceptable,” she said.
Nurses should alert doctors if they believed a patient was not receiving enough medication, she added.
Ms Henry agreed. She said Nursing Times’ findings “underline that nurses must work with colleagues to assess a patient’s needs on a regular basis.”
48% of nurses have been asked to help a patient end their life
12% of nurses have restricted patient medication for fear of prosecution
33% of nurses do not understand the law on assisted suicide
Source:Nursing Times online survey of 2,311 nurses, May 2010
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