Wednesday, May 19, 2010

Dying patients denied pain relief because of legal fears

A survey in Nursing Times has been published this morning claiming that "dying patients denied pain relief because of legal fears" - specifically that one in ten 'nurses' surveyed said that they were scared to give full doses of pain relieving opiates (even where prescribed) because of fears of being prosecuted for assisting in the death of a patient.

There are some real question marks to raise about this. First and foremost the methodology of the survey itself. This was an open survey that anyone could post to. Pro euthanasia groups were generically emailing their supporters asking for nurses to fill in the survey, but any of their supporters could have. The same may have happened on the other side. But the key point is that you did not need to be a Nursing Times subscriber or show any proof of being a registered, practising nurse to fill this in, so the results cannot be said to have a high degree of validity. The 2,311 respondents may have all been practising nurses, but there is no way to verify that. Furthermore it was a self selecting sample, so there is no way you can say this is a representative cross section of the profession.

Secondly, the survey asked distinctly slanted questions, which seem to look for answers that pointed to neglecting patients' symptoms for fear of prosecution. It was hard to give an answer that did not point in that direction without ticking an 'other' or 'not applicable' box. In other words, there was no real triangulation of data by asking different questions with different possible answers to make sure that the respondents were actually saying what they appear to have said.

In short, the methodology of the survey is so poor as to leave one wondering how many useful conclusions one could make from the data.

However, leaving aside the questions about the methodology and validity of the study, if one is to draw conclusions from it, then it does suggest a scary level of apparent ignorance of good clinical care and the law. 33% said they did not know what the law was (it hasn't changed, despite what you would have thought seeing the coverage of the DPP's guidelines on prosecution in cases of assisted suicide), and if 12% of nurses think it is better to titrate down the dose of opiate analgesics so that a patient is in pain rather than risk prosecution, that show a) a starling level of callousness and lack of care, b) a devastating level of ignorance about good palliative care and how hard it is to actually overdose someone on appropriately prescribe opiate analgesia, and c) a scary level of ignorance of the law on assisted suicide.

Has any nurse ever been prosecuted for simply giving an extra (prescribed) dose of diamorphine to a patient in terminal pain? I have never heard of such a case. You would have to give a huge dose to kill someone (people in severe pain can take considerably higher doses of opiate analgesia than people in no pain), and be either deliberately malicious or unbelievably incompetent to do so. In short, either this survey is picking up something that is not there by nature of its methodological flaws, or we really need to look again at nurse education on medical law and end of life care!

What is even more concerning is that the Royal College of Nursing has still to produce any professional guidance on this issue. The Nursing and Midwifery Council have spoken strongly, pointing out that the law has not changed, but despite the RCN changing their stance on assisted suicide to one of neutrality (supposedly to enable greater discussion of the issue), the main professional body for nurses in this country seems to be dithering and uncertain what to do. This lack of leadership may explain, at least in part, why so many nurses apparently feel ignorant and unable to act appropriately in the face of a person facing the end of their life in pain.

Leadership and education are what are needed here, not a change in the law!

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