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The Lord Bishop of Oxford: When the noble Baroness, Lady Knight, brought her Patients' Protection Bill before the House, I took her concerns very seriously and wrote to a number of medical organisations to see whether they had any evidence to support the kind of examples that she put before us. I have to say that, so far, they have not come back to me with any real evidence that supports some of the horrific stories that the noble Baroness recounted at
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that time. I find it difficult, therefore, to support the amendments in the noble Baroness's name, particularly because of the phrase "however administered", which seems to cut out any medical procedure that would legitimately withdraw artificial nutrition and hydration.

Of course there are degrees of discomfort or invasion in the way that water and other liquids are administered. Although I accept that not all administration of food and liquid artificially is invasive or burdensome, anybody who has read the Bland judgment and the description of the way in which Tony Bland received artificial hydration and nutrition cannot avoid the fact that it was a highly invasive, burdensome medical treatment.

I am afraid that I cannot support the noble Baroness's amendments but I am very sympathetic to those in the name of the noble Lord, Lord Alton, and others. Amendment No. 98 includes the proper qualification:

I think that Members of the Committee are all agreed that that kind of phrase encapsulates the long tradition of both Catholic and Anglican moral theology on the subject and best medical treatment: there is no obligation to continue treatment if it is burdensome, invasive and futile. It is perfectly proper morally, medically and in every other way to withdraw nutrition and hydration if it falls into that category.

I do not know whether that amendment is really necessary, because it seems that its contents are totally congruous with the whole spirit of the Bill. Nevertheless, I was very concerned by what the noble Lord, Lord Alton, said about the reaction of the Joint Committee on Human Rights to that. I am very grateful to him for bringing it before the House. I shall listen with great interest to the Minister's response to the Joint Committee's criticism.

Lord Turnberg: In Amendment No. 92 the noble Baroness, Lady Knight, expresses a not unreasonable anxiety that patients lacking capacity would be denied food and water regardless of whether they had made an advance directive and whether it would be of benefit to them. But the Bill seems riddled with safeguards to ensure that the idea of denial of sustenance to all and sundry could not be realised. The whole of Clause 4 describes best interests, and Clauses 5 and 6 set out how care should be provided.

The provision is applicable only in the case of patients lacking capacity who have made an advance directive that can stand up to proper scrutiny, in which they have expressly indicated that they do not want to have fluid and nutrients forced upon them through a gastric tube through their nose, a gastrostomy tube through their abdominal wall or even an intravenous fluid, none of which is absolutely free of complications. Even here the medical attendant who feels that some benefit could be derived from providing fluid and nutrients, can give it. But if
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patients gain no benefit, putting tubes into them against their express wishes could well be regarded as common assault in a person who had capacity, and we should not deny that right to people who lack capacity.

There is one area in which I agree wholeheartedly with the noble Baroness: relief of suffering is the absolute bedrock of good medical care. The denial of fluid and nutrients by mouth in the horrific stories that she described is bad practice; indeed, the Bill goes some way to trying to prevent some of that bad practice.

The other amendment in this group suggests that food and water should be given unless it is harmful or unduly burdensome to the patient. That goes some way to meeting my concerns, but I am not entirely convinced that it is necessary to state it in the Bill. There are two or three situations in which that consideration might be relevant. For patients for whom food and water are beneficial—the vast majority of patients—it is clearly wrong, and likely to be a criminal offence, not to give it. Then there are patients for whom, perhaps because of nausea, vomiting or difficulty in swallowing, giving nutrients by mouth could cause harm and be unduly burdensome. It is important to be able to give those patients nutrition by other routes such as a gastrostomy tube. Indeed, it may well be essential to do that, even though there are complications in some patients.

On the other hand, there are patients who have given a firm, advance directive that they do not want artificial nutrition should they be in a particular state and lack capacity to refuse it at the time. Why should we deny patients who lack capacity the facility to refuse artificial nutrition in an advance directive, when we cannot refuse a person who has capacity? For that reason, I do not find this particular amendment entirely attractive; it is covered elsewhere in the Bill.

Baroness Masham of Ilton: My name is attached to all the amendments because the noble Baroness, Lady Knight of Collingtree, has her heart and spirit in the right place, as does my noble friend Lord Alton. The point of Committee stage is to tease out what is right. Some provision is needed in the Bill because there is much concern on the part of vulnerable people throughout the country that they may be starved when they go into hospital. Even though there may be safeguards in the Bill, they are not firm enough for those people, who are very fearful.

My husband, when he had a serious operation, was fed by a tube through the vein in his neck for three weeks in intensive care; it saved his life. So tube-feeding is very important but it should not be done against anyone's wishes. However, we live in a very complex time: hospital food no longer comes under the domain of a nurse but under that of a housekeeping department. Those giving out food may be trained as housekeepers but are not nurses. Due care must be taken because food and fluid save lives.

It is very important to give good basic care, including mouth care, to people who have a problem eating and swallowing, as their mouths get gooed up and need to be cleaned three or four times a day.
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Nurses need that basic training. Sometimes their training is all academic and not about the actual basic care. We need to get back to TLC. I am sure that most Members of the Committee know that the phrase TLC refers to tender loving care.

4 p.m.

There are many people looking to the House of Lords for safeguards, particularly as regards patients and the provision of food and fluid. Not to have fluid or food if you want it can result in a horrible death. I hope that the Minister, who is very helpful and caring, will do something to help everyone in this matter.

Lord Winston: Because food is given out by the housekeeping department, that does not in any way absolve the nursing on the ward from responsibility for the care of the patient. In speaking to the four amendments, as a central moral principle, I have—just like the people who have tabled the amendments—the notion of the fundamental sanctity of human life, which is the central pillar of all our morality.

I am also aware of the British Geriatrics Society and its 1,400 members who very largely oppose euthanasia and totally oppose the notion of assisted dying, as I do. But I do not believe that these amendments are helpful. The truth is that illness at this stage is too diverse and too complex to be decided in this way: it has to be left to the individual circumstance.

I do not want to dwell personally too much, but four weeks ago my mother, aged 92, was admitted to hospital with severe diabetes and cellulitis of the leg, which can easily kill a diabetic. That needed massive antibiotic therapy; namely, four grams of flucloxacillin and four grams of ampicillyn every six hours. When that was not tolerated by mouth, the question was whether it could be given by intra-muscular injection. Clearly, that would be totally unacceptable and an extremely torturous thing to do.

When my mother was conscious and able to refuse, she refused to have an intravenous line put up. Sometimes, of course, she was just unconscious and not able to refuse. But putting a line up was excessively difficult. I watched her nursing with great concern. Throughout the two weeks that my mother was in hospital, a close member of my family sat with her throughout the day until 11 p.m. So I saw exactly the nursing in that ward, not only with my mother but also with other people who were often in extremis.

On one occasion, I was so distressed by the attempts of the quite senior registrar to put up an intravenous line that I said, "Hold on a bit. I am surgically qualified. Would you like me to have a go?". It is not easy to put up an intravenous line on one's mother. I got it into the vein, but it immediately clogged up. At that point, one has to make an individual decision. Basically, one asks oneself, "Do I go on accepting that my mother will be tortured by repeated attempts at veinipuncture or do I accept that her autonomy in this situation is really rather important?".

I came to the conclusion that if my mother was to die in that situation, her dignity should be respected. To continue to offer her that treatment, which probably
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would not help anyway, was unacceptable. It was an individual decision made by me as a relative, as geriatricians frequently have to do in consultation with relatives.

I do not understand this, but, remarkably, someone intervened. In spite of my mother not having that massive antibiotic therapy, after 48 hours the cellulitis resolved. She had no treatment, nor was she properly drinking or properly hydrated most of the time. She could not tolerate fluids because she was vomiting everything. But her leg started to get better and two weeks after her admission she was discharged from hospital. She has been at home for the past four weeks.

There comes a point when we should accept amendments to a Bill, which already covers those issues. This Bill strengthens practice; it does not diminish it. I doubt whether these amendments would allow for the individual circumstances of patients under proper medical care where there is not a dereliction of duty of medical practice, as my noble friend Lord Turnberg has mentioned.

I have to apologise to Members of the Committee. I would like to hear the response to the amendment from my noble friend the Minister. But, during Question Time, I heard that, four weeks after my mother's discharge, she has been admitted to hospital in coma again. I intend to leave Westminster as soon as I can. I shall sit for another half an hour, because I think that she is still being triaged in casualty. But I doubt whether I shall be able to stay until the end of these amendments.

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