66.Memorandum from Ms Teresa Lynch (MIB
1. The government gives repeated assurances
that it is opposed to euthanasia. However, euthanasia does and
has included withholding or withdrawing tube-feeding with the
intention of bringing about the patient's death since the early
1990s in this country. In addition, the Voluntary Euthanasia Society,
whose aim is to establish the right to kill and be killed, has
assisted the Government in its documentation relating to decisions
required for treatment or lack of treatment for those patients
who may or may not be at the end of life.
2. "Competence" is a dangerous
word to employ in these situations. No right thinking individual
would readily agree to death by starvation and dehydration. Proper
informed consent is doubtful in situations where lay people are
to be involved in such momentous decisions over life and death.
It is surely not humane to put either "competent" or
"incompetent" patients through such avoidable stress,
where reasonable means can be employed to ensure best clinical
3. The British and European courts overwhelmingly
rejected the concept of a "right to die" in the Dianne
Pretty case. Patients in a vulnerable state will perhaps feel
that euthanasia is the best option open to them, in particular,
4. Financial expediency is never the answer
to a "problem" of a vulnerable individual or any group
considered to be economically or physically "non-viable".
The increasingly-used term "bed-blockers" will become
prime candidates for the abandonment of care.
5. Patient quality of life should not be
considered on physical condition alone. Dignity, like autonomy,
can only be generated by trusting relationships. The right to
good clinical care is a paramount right of any patient, and the
first responsibility of any individual, worthy of the name of
Doctor, Nurse or Parliamentarian.
6. Lastly, in my professional opinion, the
foreseeable implications of such a Bill are profound in relation
to future motivation, recruitment and retention of both nurses
and doctors. To my certain knowledge, the sinister encroachment
of bad guidance on the duty of care is causing attrition rates
in both professions, so long dedicated to the well-being of patients.
Such a Bill if passed, in current form, will reflect both a total
lack of compassion for people in need and respect for professional
vocation, training and expertise.
I hope these points may assist you in your deliberations.
Draft Mental Incapacity Bill submission:
The Rights of nurses who may encounter distressing clinical directives
in the work place
The labour of nursing is acknowledged as comprising
both physical and emotional elements to be part of their work.
Recent national and professional guidance may now be an unforeseen
pivotal factor in the attrition rates of nurses both prior to
and post the nurse registration process.
1. What support will be available to nurses
(and Doctors) who are unable to follow clinical directives which
are incongruous with their own belief systems?
2. Nurse attrition rates: a frequent result
of unresolved stress when attempting to work with repeated ethical
conflict in the clinical area?
Considerable changes in the training and expectation
of nurses have occurred over time. These were designed, in part
to manage the reduction in junior doctor hours, and would herald
a new view of nursing among co-professionals.
The climate in nursing in the UK is one of a
developing autonomy with nurses taking on an increasing number
of these expected developed roles. Progress is ongoing on the
plan for nurses to be able to prescribe a more comprehensive range
of medications than the current limited amount agreed by the Medical
profession. Nurses are now able to be Consultant Nurse Specialists,
Physician/Surgeon assistants and even take on the role of Endoscopist.
To some extent these changes have increased the acceptance of
nursing as a profession on a par with other University-based,
professional training programmes. Closer links have evolved between
the medical and nursing professions. Nurses are expected to take
on the roles formerly within the province of junior medical staff.
The profession of nursing is now linked increasingly to the responsibilities
This technical aspect of the nurse's role expansion
and the professional recognition has not always equated with the
expected recognition in other more expressive areas of nurses'
work which also involves close association in medical decision-making.
Medical staff can now dictate a decision for withdrawing or withholding
life-prolonging medical treatment (British Medical Association
1999). Such situations can distress many nurses, whose long-held
wish, in most cases, would be to maintain their caring skills
to meet the needs of their patients for both physical and psychological
Care is perhaps the most basic element of a
patient's treatment that a nurse can provide, yet it is the most
The term "Care" is derived from the
Anglo-Saxon "to trouble oneself". This impulse, together
with the desire for nurses to put the interests of others' good
before their own, can be a clear declaration of a nurse's own
"The Essence of Care" Department of
Health initiative was developed with the active participation
of patients and their carers as well as hundreds of health professionals.
It offers a practical toolkit to be used a part of quality improvement
programmes. It will also become an integral part of clinical governance
at local level.
The eight areas addressed by "The Essence
of Care" document are: privacy and dignity; nutrition; principles
of self-care and record keeping; personal and oral hygiene; continence
and bladder and bowel care; pressure ulcers; and the safety of
clients with mental health needs. They are all seen as fundamental
to achieving the basics of care. The "Essence of Care"
defines patient-focussed best practice and then sets out the steps
necessary to achieve the benchmark. Staff can use the pack to
work with multi-disciplinary colleagues and patient representatives
to consider how well they are performing in structuring the sharing
of good practice within comparison groups and across an organisation.
The clear role of nurses who wish to care for patients in line
with such ideals can conflict with the professional views of others
in certain clinical situations.
A form for such caring impulses can be seen
in the role of the nurse as Advocate. This role has been described
as one of the most difficult a nurse has to face. Advocacy has
been described as "not a slogan or a hobby, nor to be entered
into by the faint-hearted" (Copp 1984). The advocate role,
though not only expected of the nurse within the multidisciplinary
team, can often be an inevitable result of the twenty four-hour
responsibility of nurses for patient care.
Patients' own Care plans were generated with
the aim of giving individual patient care, and have been part
of the nurse's care orientation and training for over thirty years
in this country as in America.
There are various reasons for the nurse finding
difficulty in the role of advocate. Despite good approaches that
have developed in multidisciplinary team work (particularly in
the field of Gerontology). The Doctor is often the ultimate arbiter
of any treatment plan.
Recent Medical guidance has abrogated one of
the historical functions of the nurse. Helping patients with their
nutritional needs, whether involving assisted food and fluids,
has always been an expected part of the total nursing care of
The original BMA guidance and the following
guidance of the General Medical Council (2002), in relation to
assisted food and fluid as "treatment" is opposed by
many nurses, but application of such guidance, may become the
norm in practice.
The guidance from the BMA, was the result, in
part of the notable case law in relation to the young man, Tony
Bland, who was suffering from what is described as a "persistent
vegetative state". This case elicited from one of the lawyers
at the time, a warning that nurses involved in this case would
have to cope with being expected to go against all their training
preparation, but would need to realise that the agreed course
of action, (discontinuation of the feeding programme), would be
in the best interest of all concerned.
Nurses are bound by their professional Code
of Conduct. Their unchanging professional expectation is the clear
duty of care, to safeguard the public and at all times to put
their patients' interests and safety first (NMC 2002).
Despite this Code, some nurses are placed in
positions of conflict by the demands of other professionals, managers
and contexts of employment which may clearly compromise their
duty of care. Such situations can induce considerable stress for
the nurse, who attempts to act as patient advocate and not least
when threats of disciplinary action or suggestions that they are
not coping, are employed against them.
The National Framework for older people aims,
among others, to make treatment decisions on the basis of clinical
need, not age. The overall aim backed by £1.4 billion (invested
every year by 2004) is better health and social care services
for older people (DOH 2002). This move may prove beneficial to
those who are supported at home by the Government's community
care aims for older people. The number of people over 90 years
of age will double in the next 25 years. There are examples of
poor, unresponsive and insensitive treatment and sometimes, simply
because of the age of patients. Denying access to services on
the basis of age alone is not acceptable. The Government's drive
to raise standards of care, particularly those relating to patient
empowerment, is not restricted to the NHS and extends to the independent
sector. The consultation document "For the Future" (DoH,
1999) epitomised the Government's commitment to establishing required
standards for residential and nursing homes in recognition of
the somewhat sketchy regulations set out in the Registered Homes
Act (DoH, 1984).
Another source of conflict (and confusion) for
nurses, results when worthwhile initiatives, propelled by national
directives can be seen to contradict other, more questionable
The Government, in October 1999, publiched its
proposals to reform the law on mental incapacity, which have now
been enshrined in its draft Mental Incapacity Bill (2002).
By April 2002, draft "guidance" was
issued by the Government on management of people unable to make
decisions about their own treatment and care. The Government claim
that it does not wish to introduce active euthanasia but is silent
about euthanasia by neglect. It is moving ahead with plans that
would introduce the routine denial of assisted nutrition and hydration,
which could be labelled as passive euthanasia.
This Bill applies to any adult who is mentally-incapacitated
and will therefore affect every single person in this country,
because everyone is vulnerable to accidents or illnesses that
may cause mental incapacity. The Bill's radical proposals include
using a system of living wills and unqualified, unaccountable
attorneys to force doctors to withdrawing life-sustaining treatment
and care (commonly understood to include also assisted food and
fluid). If passed, the Bill will be the first comprehensive law
in the world allowing euthanasia by neglect and may become a model
for all common-law countries.
This new draft guidance has been launched with
the aid of the Voluntary Euthanasia Society and the clear aim
is to allow the starvation and dehydration of incapacitated people.
The guidance also recommends the use of the "living will"
drawn up by the VES. No mention is made, however, of the known
pitfalls of "Living Wills" or "Advanced Statement
This guidance will affect people able to feed
themselves but who need considerable basic medical and nursing
care, (eg elderly and or disabled people). In many cases these
people will not die but become chronically-sick "bed-blockers"
with little prospect of alternative accommodation in light of
the many nursing home closures in recent years.
The Mental Incapacity Bill could lead to a possible
situation where one statement which request or agrees to a refusal
of treatment would be all that is required to end that patient's
life once the stage of mental incapacity is reached. For a doctor
to continue to administer treatment (including assisted food and
fluid) would be illegal.
The nurse who cannot agree with some of the
planned changes, and certain defeatist approaches to those most
vulnerable, may feel compelled to leave his or her chosen profession.
This may become the only possible course of action, if unsupported
in the view that the duty of care should not be ignored devalued
or interpreted with malice.
Professionals, relatives and employers may argue
that the expedient action or omission of care, which they may
believe to be "in the best interests" of the patient,
is also in line with a human right to "die with dignity".
The nurse, who believes that human dignity is
not contingent on physical condition but inherent to the individual,
and like autonomy, is dependent on trusting relationships, may
only experience the vision of patients in need, being abandoned
by their carers.
Nurses and Doctors also have human rights. The
professions need to examine what impact on their mentors (and
patients in turn), will result if these rights to practise within
a vocational, caring perspective are denied.
Department of Health (2002) National Service
Frameworks for Older People Short summary, 22 April.
Nursing and Midwifery Council (2002) Revised
Nursing Code of Professional Conduct.
Department of Health (2001) The Essence of
Care. Patient-focussed benchmarking for health care Professionals.
General Medical Council (2001) Withholding
and Withdrawing Life-Prolonging treatment. (Draft) Guidance for
Department of Health (1999) Consultation
Document, "For the Future".
British Medical Association (1999) Guidance
on Withdrawing and Withholding Life-Prolonging Medical Treatment.
Department of Health (1999) Making Decisions:
Helping people who have difficult decisions for themselves. HMSO.
Smith P (1992) The emotional labour of nursing.
Its impact on the interpersonal relations, management and the
educational environment. MacMilan, Basingstoke.
Cope LA (1986) The nurse as advocate for vulnerable
persons. Journal of Advanced Nursing 1193): 255-63.
Department of Health (1984) The Registered