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Special Report

has to be done’. This would appear to suggest more should be done rather than do less.

It is important that best interests would not be determined merely on the basis of, or following unjustified assumptions around, irrelevant factors such as her age or malignancy.

Quality of Life

Questions that need to be considered include: what impairment/distress is the patient experiencing? Will the quality of life post-intervention be acceptable to the patient? Are there plans for palliative care?

Mrs Jackson had been independent and enjoyed the company of friends and neighbours. Before this situation arose, her quality of life was unclear, although presumably it was poor. Crucially, the team might ask if her independence has already been lost forever. While eating little and relying on visits from an elderly neighbour it is unclear if this level of quality of life could be improved to become more acceptable. Successful treatment of any overdose would not affect her quality of life positively or negatively. Although treatment would provide an opportunity to try and improve her quality of life. Without treatment she would most likely die, where no quality of life can be demonstrated. There is no evidence that her current/best potential condition was such that continued life might be judged undesirable. However, if her preference was not to continue to live no quality of life may be acceptable to her.

Contextual Features

Are there family factors that might influence decision-making? Are there religious, cultural or legal concerns that need to be taken into account? Are there conflicts of interest?

Mrs Jackson’s son is in Canada and it seems that her neighbour, Mrs Brown, has taken on a key carer role. The hospice team will require more information about her family in Canada and about any religious and, perhaps, cultural matters that may influence her care. The team may also wish to speak with Mrs Brown and with Mrs Jackson’s consent, if possible, with her son in Canada. Crucially, the hospice team have to weigh Mrs Jackson’s healthcare requirements against other claims for a hospice place, which is a scarce resource, and the team may have to decide which of a number of patients will get the hospice bed.


Mrs Jackson was offered a hospice bed and was transferred by ambulance. After some hours her confusion resolved and she appeared to regain capacity to make decisions about her care. She made it clear that she was unhappy with the decisions of her neighbour and GP. She agreed to stay overnight in the hospice and to have a discussion with a consultant the next morning. During this discussion she disclosed that she had taken an overdose of paracetamol at home. She was advised that, in these circumstances, she would normally be moved to hospital. Mrs Jackson agreed to be moved to the hospital, which was closer to home, and agreed for her son to be contacted. Her son made arrangements to travel to the UK and during his stay visited her daily in hospital. Her experience in hospital was not a happy one. Her son felt that staff members were uncaring and communication about his mother’s care and treatment was almost impossible. It was his belief that her suicide attempt had influenced the decision to withdraw medical treatment. After 10 days, Mrs Jackson encouraged her son to


return to Canada. He was at Heathrow Airport when he received a phone call from the hospital to say his mother had died peacefully. He said he decided not to complain about his mother’s care because it would not have done any good.


Ethics cases are rarely tidy or unidimensional. They require practitioners to engage with the ‘swampy lowlands’ of everyday practice.8

There is

no panacea but frameworks can help to structure thinking and discussion. There is also value in considering difficult decisions from different perspectives. An understanding of ethics and professional codes is essential for professional accountability.

Everyday ethics in cancer care can be challenging and there are many more difficult decisions than we could address in this article. However, the case of Mrs Jackson does challenge us to engage with multiple perspectives and complexity. It is difficult for practitioners to respond to those who refuse treatment and who appear not to value their own lives. However, practitioners can seek advice from trusted colleagues or from a Clinical Ethics Committee (see, for example, UK Clinical Ethics Network) if their organisation has one. However, what we should not forget is the consequences of our decisions for patients and families. The GP’s decision to opt for hospice admission is likely to have been influenced by his knowledge of Mrs Jackson and by her expression of her wishes in a living will. He had no way of knowing if at some point in the period following her overdose she changed her mind. Although the living will may not have had legal status, it had ethical weight. Therefore, the GP’s response may be described as being wise, compassionate and respectful in the case of Mrs Jackson. He did not go against her wishes as expressed in the living will and he did not abandon her. The challenge for professionals is to determine what constitutes an ethical response in these particular circumstances. It is possible that members of the hospice team could have interpreted the GP’s request for hospice admission as well-meaning but perhaps reflecting the path of least resistance rather than the product of best interests decision-making. Declining admission and supporting hospital admission may have represented professional virtues of wisdom, respectfulness for life and justice. The hospice team are acutely aware that beds are scarce and may have taken the view that the preservation of life outweighed any previous wishes. To reiterate the point made above, two virtuous practitioners may come to different conclusions in terms of what is the most appropriate ethical response in the same situation. Of course, what professionals think is an ethical approach is not always what patients and families think is best and we must take this seriously. We leave the final words to Mrs Jackson’s son. He said:

“Mother was nearly 92. She had loved life but no longer had the health to continue. She was depressed, unwell, lonely and most of all, bored. What could anyone have done to help her when she was ready to make up her mind to end it all? In regard to her final weeks, I’d say frank and open discussion between the patient and family by the professionals would have been critical to provide the basis for an appropriate and agreed treatment regime and proper planning for the last days. Instead we were faced with the opposite and given the mushroom treatment (meaning they are kept in the dark and not given information).

I’m not sure if any of this is of value but, in summary, I felt powerless to deal with my mother's position. I'm known as a fixer but the system


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