Memorandum by the Royal College of Nursing
of the United Kingdom
The RCN is against the proposals in this Bill.
Our primary concerns are:
More attention needs to be given
to the provision of high quality palliative care, available to
all who need it. This must include proper pain control and psychological
care. We feel that it is imperative to address the palliative
care needs of dying people in order to make their last days more
comfortable, rather than clinically assisting death. Patients
want control, dignity and comfort.
There is a real danger that the proposals
in the Bill could undermine the nurse-patient relationship, leading
to a culture of fear amongst vulnerable people at a time when
they most need to feel supported by their clinical team.
The proposals in the Bill will be
unacceptable to many nurses on moral, ethical or religious grounds.
Nurses in all clinical settingsnot just specialist palliative
care nursescould potentially care for dying patients. It
is not a discrete area which is easy to opt out of in the way
that, for example, abortion is.
Respect for the intrinsic value of
all life is central to nursing. The proposals in the Bill normalise
the concept that the lives of those affected by serious illness
are not worth living.
These proposals could put pressure
on many vulnerable patients, who might feel a duty to use the
provisions in the Bill to avoid becoming a burden on their families.
Further, relatives who can't bear to see their loved ones in pain
may put pressure on clinicians to inappropriately assist deathrather
than addressing the core problem, which is ensuring appropriate
pain relief and symptom management.
1.1 With a membership of over 370,000 registered
nurses, midwives, health visitors, nursing students, health care
assistants and nurse cadets, the Royal College of Nursing (RCN)
is the voice of nursing across the UK and the largest professional
union of nursing staff in the world. RCN members work in a variety
of hospital and community settings in the NHS and the independent
sector, and in educational settings. The RCN promotes patient
and nursing interests on a wide range of issues by working closely
with Government, the UK parliaments and other national and European
political institutions, trade unions, professional bodies and
1.2 Nurses deliver 80 per cent of hands
on care to patients, and are often the closest clinicians to them
towards the end of life. Nurses can support patients and families,
and have a key role to play in communicating and information sharing.
The comfort and dignity of dying patients is potentially a responsibility
of registered nurses and health care assistants working in all
settings, as well as for specialist palliative care nurses.
1.3 The RCN has a wide membership which
naturally reflects a variety of views. We have looked at a wide
range of comments from our members and have decided to maintain
the position reflected in this paper on behalf of both nurses
and patients. Overall, our membership is opposed to the proposals
in the Bill.
2.1 RCN members feel strongly that high
quality, easily accessible palliative care services, which meet
people's physical and psychological needs, should be in place
for all patients who need them. Adequate pain and symptom control
management could alleviate some of the concerns which lie behind
2.2 Patients do not always have adequate
choices in palliative care. Differing provision across the UK
has created a system where the level of palliative care received
is often dependent on location. Nurses want to ensure that all
their patients receive the appropriate high standard of care wherever
they live, and irrespective of illness, both in acute settings
and in the community. Patient choice is particularly important
in palliative care; however a shortage of community palliative
care teams means that patients who want to die naturally at home
are not always given that option. In particular, while adults
with a cancer diagnosis for the most part now receive good palliative
care services, many patients with other terminal diseasessuch
as degenerative motor neurone disease or chronic obstructive pulmonary
disease (COPD)are not able to access appropriate services.
This gap in provision needs to be urgently addressed. RCN members
debated this at our annual Congress in May 2004 and voted overwhelmingly
to lobby for improved palliative care services.
RCN member: "I have nursed at least one
patient who was adamant he wanted to die, but when his quality
of life had been improved completely changed his decision. How
many more cases are there like this?"
RCN member: "Unrelieved (intolerable) pain
is often cited as a reason for people wanting to die. However,
hospice doctors tell us that even intractable cancer pain can
be relieved in 90 per cent of patients and significantly relieved
in the other 10 per cent.
Once a patient's symptoms are under reasonable control, few people
who requested euthanasia on initial contact with a hospice persist
in doing so. The answer would appear to be to increase the provision
of hospice care rather than legalising voluntary euthanasia."
2.3 These issues were highlighted recently
by the thorough report on palliative care produced by the Commons
This report also noted that palliative care services are often
not culturally sensitive, and this must be addressed.
2.4 The Bill contains provision that a patient
with a terminal illness shall be entitled to receive pain relief.
This right already exists and all patients who need it should
be able to access pain relief without the need for this legislation.
The responsibility of nurses, working with others from the multi-disciplinary
team, is to ensure that the final weeks of those with a terminal
illness are as pain free, positive and dignified as possible.
Clause 15 is unnecessary.
2.5 What is needed is better training, education
and resources for all clinicians to ensure that they have a proper
understanding of pain control. This must go hand in hand with
a properly funded service across the UK for all who need it. Complementary
therapies also play a significant part in palliative care sought
by patients and this area should be given more attention.
2.6 A situation where a clinician delivers
drugs deliberately to end someone's life is very different to
a situation where a person administers drugs with the aim of relieving
pain, even if that action may have the secondary effect of hastening
death. The RCN does not consider that Clause 15 changes that distinction;
nor that it should.
2.7 In particular, we must guard against
the provisions in this Bill being used as a substitute for universal
provision of palliative care services. Several members raised
the fear that provisions in this Bill could be inappropriately
used to ease the economic challenges of providing long term and
3.1 For some patients, social issues or
psychological distress may lead to feelings of wanting to end
life. This is indicative that appropriate mental health services
and psychological support are not being provided. Culturally appropriate
psychological support is a key component of care, and must be
provided as part of the care package. We do not feel that adequate
provision has been made for this in Clause 8, which deals specifically
with patients who lack competence.
3.2 As an RCN member pointed out, the desire
in terminally ill people to die is recognised as being transient
"A study reported in the American Journal
of Psychiatry noted the `inherent transience' of the desire
for death in many terminally ill patients. This desire, it said,
is closely associated with depression`a potentially treatable
condition'and often diminishes over time."
3.3 This highlights the need for a comprehensive
4.1 The Bill anticipates the potential assistance
of nurses in assisted dying; however nurses as a professional
group have little mention in the wording of the Bill. For example,
there is no mention of counselling or education for nurses expected
to be involved in these procedures.
4.2 The RCN feels strongly that the proposals
in the Bill could jeopardise the nursepatient relationship,
eroding public trust in nurses. It is nurses' duty to protect
the weak and vulnerable, and any perception that they would not
act in this way could generate a culture of fear among vulnerable
people. Some members commented on the vast shift in the cultural
and ethical basis of nursing which would need to be made in order
to justify participation in assisted dying.
RCN member: "Would there be a lack of trust
between patients/carers/practitioners once the `goalposts' have
RCN member: "As a nurse I would be very
uncomfortable working in a health system that assisted people
to die when surely we should be striving to care for people's
physical, mental and spiritual health in this life."
5.1 The proposals in this Bill would be
objectionable to many nurses on moral or ethical grounds, or for
religious reasons. Although Clause 7 touches on the right of objecting
physicians to refer patients on, it does not adequately deal with
the rights of the wider clinical team. Further, nurses in all
settings potentially work with terminally ill patients. This is
not a discrete area which is easy to opt out of in the way that,
for example, abortion is.
5.2 The difficulty in opting out of assisted
dying could create real tensions in settings such as small nursing
homes, where there are fewer numbers of registered nurses. If
even one or two wish to opt out of dealing with those patients
who request assisted dying, maintaining an appropriate level of
care would be a challenge.
6. EQUALITY AND
6.1 RCN members have expressed concerns
that the proposals in the Bill devalue life by normalising the
concept that the lives of those affected by serious illness are
not worth living. Nurses feel strongly that all individual lives
have intrinsic value, with equity of access to treatment being
a cornerstone of nursing.
RCN member: "As nurses we want to promote
patient rights but not at the expense of our responsibilities
as nurses (our duty to care) and in society to protect the weak
6.2 Ageing, sickness and dying are part
of life and several members were wary of trying to inappropriately
intervene clinically in their due process. Members commented that,
however emotionally difficult, a natural death with time to say
goodbye can ultimately be peaceful for patients and therapeutic
RCN member: "palliative care medicine/nursing
provides end of life care that, in most cases, provides relief
from the distressing symptoms of terminal malignant disease, allowing
precious time with loved ones. And for those without carers or
family, it is my experience that some isolated, lonely people
have died in an environment where they feel loved and cared for.
Is this not what the medical and nursing profession is about?
It is my conviction that knowledge of the skills that produce
effective palliative care are still widely unknown amongst medical
and nursing staff and even less so amongst the public."
7. PRESSURE ON
7.1 Many RCN members voiced the fear that
vulnerable patients, and especially older people, would feel a
duty to use the provisions in the Bill in order to avoid becoming
a burden on their families. We do not consider that there are
sufficient safeguards to avoid this. Further, we have concerns
that relatives could inappropriately place pressure on relatives
to request assisted dying, and that again safeguards were not
in place to prevent this.
7.2 Such pressure would be exacerbated if
the necessary palliative care package was not in place. Again,
there is a real concern that assisted dying could inappropriately
replace properly funded and implemented quality end of life services.
RCN member: "The most important people
to consider are the patients. If they were to think that this
was a possibility, would they also think there was a responsibility
on them to die quicker so that they wouldn't be a burden?"
7.3 Families would also come under pressure
to relieve their relatives of pain where appropriate palliative
care services were not available. However this would not be addressing
the core problem, as one RCN member put:
"I have absolutely no doubt that introducing
legally acceptable assisted death will put unbearable pressure
on both patients and their families at a time when they are at
their most vulnerable. This was brought home to me in a most tangible
way with death from heart failure of my own father eight years
ago. It has long been known that death from heart failure can
be an agonisingly slow and painful process and that none of the
palliative care so effective in cancer sufferers is currently
available to them. My father had a horrible time dying and it
was an extremely difficult time for the family. The GP was unwilling
to provide morphine (in case it depressed cardiac function) and
he suffered a great deal of pain. Had assisted death been legal
at the time I would have felt under extreme pressure to ask for
it, and indeed many was the time that I contemplated in my mind
at least, smothering him with a pillow to put him out of his pain.
However we persevered with the GP and eventually morphine was
prescribed. I cannot begin to describe the difference that this
made. Suddenly my father was pain free, he rallied enough to receive
the family and died in peace knowing that the end was near but
free from the fear that the constant pain of a failing heart.
Our family was left with memories of a good death."
7.4 Again, this highlights the need for
a comprehensive care package.
8. LEGAL ISSUES
8.1 Competent adults already have the right
to refuse any medical treatment even if that refusal results in
their death. It is important that patients understand their right
to refuse treatment, so that they are not in fear of inappropriate
and unwanted medical intervention. Conversely, it is legal for
clinicians to administer medication with the purpose of reliving
pain, even if that medication may have the secondary effect of
hastening death. Nurses can play an important role in communicating
this. The Mental Capacity Bill currently progressing through Parliament
will enshrine in legislation the authority of advance decisions
by patients to refuse certain treatments. The RCN welcomes this
inclusion as a valuable tool to help those people who may lack
capacity in the future. We consider that the Mental Capacity Bill
further strengthens the argument that the Assisted Dying Bill
8.2 The RCN does not consider that the safeguards
in the Bill are robust. For example in the Schedule the expression
"appears to be of sound mind", in the opinion of the
legal and other witness to the declaration, is vague and undefined.
Further, the definition of "competent" is also very
vague, and appears to bear no relationship to the understanding
of competency either at common law or under the forthcoming Mental
Capacity Bill (and its Scottish equivalent, the Adults with Incapacity
(Scotland) Act 2000). The expression "terminal illness"
is imprecise given the role it plays in this Bill's criteria for
eligibility. Many patients have been told they have days to live
and have gone on to live for months or years.
9.1 For the most part nurses do not consider
that the proposals in this Bill will better support patients,
but that the imperative should be to provide improved palliative
care for those with terminal illness. Culturally appropriate palliative
care and psychological support should be available to all who
need it. The RCN does not support this Bill.
2 Twycross, R (1994) Pain Relief in Advanced Cancer.
London, Churchill Livingstone. Back
Commons Health Committee (2004) fourth report of session 2003-04
HC 454-1HMSO. Back
Chochinov, Wilson et al (1995) Desire for Death in the Terminally
Ill, American Journal of Psychiatry 152:8, 1995. Back