Clinical dilemma - A patient dying of lung cancer

The Dilemma
A 70-year-old woman who is dying of lung cancer belongs to a neighbouring practice where I do some Saturday mornings. I am asked to visit because she is in pain. I arrive to see her peacefully asleep in bed surrounded by six anxious relatives. They have phoned the hospice, who advised ringing me, so that I can give her an injection. She is already on fentanyl 100 patches, doesn't appear to be in pain and resting peacefully. What is more, on shaking, she opens her eyes and tells me that she is comfortable and that I can't do anything for her. No matter which line I take, the family cannot be dissuaded from their belief that she needs an injection. I try to explain that she is peaceful and looks to be near to death, but they imply that they want me to accelerate her death.
What should I do?

A GP's view

Dr Raj Thakkar, a GP in Wooburn Green, Buckinghamshire

If put under pressure by relatives, the questions to ask yourself are: 'Am I acting in the patient's best interests?' and 'Can I justify my actions?' The patient is not in pain and it is important to establish who thought they were and why?

Perhaps the individual or individuals concerned have ideas and anxieties that need exploring and that explaining she is comfortable is all that is required. Family members may become angry if they think you are withholding treatment.

It may prove a little difficult to dissuade the family if the hospice suggested she requires an injection, albeit on the basis of dubious information. Contacting the hospice, discussing the real symptoms and conveying their views back to the family may persuade the family to change their mind.

It is also important to clarify what exactly they want to achieve by administering the medication.

Giving an injection to relieve pain is justified. It may, however, hasten death as a side-effect, known as the doctrine of double effect. On the other hand, giving a drug for the sole purpose of accelerating death is unlawful.

Explain to the family that it is illegal to administer the drug under these circumstances. If they become angry, your own safety must be preserved and you may be required to call the police. Irrespective of how insistent the family are, you must not give the injection.

A medico-legal opinion

Dr Marika Davies, Medico-legal Adviser, Medical Protection Society

You have made an assessment of your patient and do not consider her to require any further pain relief. Recent case law has established that it is for the clinician to decide what treatment options are clinically indicated.

In addition, according to GMC guidance as set out in Good Medical Practice, you must prescribe drugs or treatment only when you are satisfied that they serve the patient's needs, and it would be inappropriate to prescribe an injection for your patient purely at the request of the family.

The family may feel that they know what is best for their relative but if she is competent they do not have the right to make decisions on her behalf. The first principle of the new Mental Capacity Act is that a person is assumed to have capacity unless it is proved otherwise.

Good Medical Practice also states you must be considerate to those close to the patient, and be sensitive and responsive in providing information and support. It may be that your patient was in pain previously, and you should make arrangements with the family for if she becomes uncomfortable again. They may also need reassurance about the care that will be provided to ensure a peaceful death.

A patient's view

Ailsa Donnelly, Member of the RCGP Patient Partnership Group

I have immense sympathy with the relatives, who are probably aware of the proximity of death and both scared and panicking.

Most people have never seen anyone die and a common perception is that death from cancer is always painful and needs medical attention.

Why did the relatives phone the hospice initially? Was the patient actually in pain then? If so, is it likely to recur? The GP must take time to listen and tease out their concerns, as well as explaining exactly what will happen leading up to and at the point of death, giving an approximate time scale if possible.

What the relatives need most is reassurance and confidence that they can give her a 'good death'. If the patient can confirm that she is not in pain that would be a powerful message.

The GP may be misinterpreting the relatives' fear that they cannot manage the dying process by themselves as them wishing to accelerate her death. It would be helpful to give them pointers to watch for that indicate the patient is in pain, and the GP should not leave without leaving a contact number for emergency help.

Relatives would feel reassured if they knew the GP, Macmillan or district nurse would call later without them asking.

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