Memorandum by the Nursing and Midwifery
The Nursing and Midwifery Council (NMC) is an
organisation set up by Parliament to protect the public by ensuring
that nurses and midwives provide high standards of care to their
patients and clients. As a regulatory body for nursing and midwifery,
the primary function of the NMC is public protection through professional
standards. One of the most important ways of serving the public
interest is by the provision of advice and guidance to our registrants
on professional issues.
The Council has 23 voting members, of which
12 are practitioner members and 11 are lay members. Meeting quarterly,
they set Council policy.
The Nursing and Midwifery Council would like
to submit evidence on the Assisted Dying for the Terminally Ill
Bill [HL] by:
Commenting on the relationship of
the bill to the field of palliative care that nurses practise
in both generalist and specialist roles.
Commenting on the role of the nurse
as defined in the bill.
1. The Nursing and Midwifery Council is
aware that there has been an identification of inconsistencies
in palliative care services in the report Palliative Care Fourth
Report of Session 2003-2004 (House of Commons Health Committee
2004). The report recognises that there exists inequity by geographical
area, by patient group and by disease group. This report also
recommends that the skills of healthcare staff are raised and
that training in palliative care becomes part of continuing professional
development. Recurrent themes run throughout the report regarding
issues of patient choice, equity of care, communication, recognition
of cultural beliefs, workforce issues and quality assurance. Palliative
care is defined by the World Health Organisation as an approach
"that improves the quality of life of patients and their
families facing the problems associated with life-threatening
illness, through the prevention and relief of suffering by means
of an early identification and impeccable assessment and treatment
of pain and other problems, physical, psychosocial and spiritual".
The WHO declares that palliative care "provides relief from
pain and other distressing symptoms; affirms life and regards
dying as a normal process" and it "intends neither to
hasten or postpone death". The NMC welcome the recognition
within this Bill that the main concern is to relieve suffering.
However, the Nursing and Midwifery Council is concerned that there
is potential conflict for the role of the nurse working within
palliative care. Specifically paragraph 3(1) which states that
"the attending physician shall ensure that a specialist in
palliative care who shall be a physician or nurse has attended
the patient to discuss the option of palliative care" and
the definition of "unbearable suffering" [paragraph
2:2(d)] defined as "suffering whether by reason of pain or
otherwise which the patient finds so severe to be unacceptable
and results from the patient's terminal illness". The NMC
is concerned that due to the aforementioned report of inequalities
around the provision of palliative care and the recognised need
to improve the education of health professionals that nurses may
be placed in challenging professional and ethical positions should
a patient request assisted dying which might actually be a direct
consequence of inequity of local service provision.
2. There is no comprehensive definition
of the nurse within the Bill. The NMC is concerned that paragraph
2, provides clear definitions of the roles of the attending physician
and the consulting physician but only identifies nurses as a member
of the medical care team "assisting the attending physician".
A diverse group of roles are practised within the specialty of
palliative care by nurses with varying degrees of responsibility
and autonomy. Nurses are more often than not the principal professional
for patients who are in the end stages of life. This has not been
adequately addressed by the Bill.
3. The NMC recommend that conscientious
objection in paragraph 7(2) should not just be identified for
medical staff and should include nursing staff. Although medication
will be prescribed by the physician nurses may be ultimately responsible
for the administration and titration of the medications to keep
the patient free from pain and distress as stated in paragraph
4. Paragraph 13 sets out the requirements
for documentation. The NMC is concerned that there is no consideration
of nursing documentation. The Nursing and Midwifery Council believes
that record keeping is a fundamental part of nursing and midwifery
practice and it is recommended that this is incorporated into
5. Paragraph 14 sets out the monitoring
commission and reporting requirements. The NMC is disappointed
that there is no recommended nursing member on the monitoring
commission. The NMC acknowledges that palliative care is undertaken
within a broad multiprofessional framework, however, the role
of the nurse within the speciality is a fundamental one and there
are distinct regulatory and professional issues to be monitored.
The Nursing and Midwifery Council recognises
that there are strong views within the nursing profession regarding
The NMC Code of Professional Conduct: standards
for conduct, performance and ethics (2004) states that nurses
must protect and support the health of individual patients and
clients. The Code also clearly directs that nurses must respect
the rights of the individual and the patient/client's role in
planning their own care. Nurses are advocates for the patient/client
and have a legal, moral and professional duty to care recognising
the patient/client's right to individual choice at all times.
The NMC welcomes the recognition within the
Bill that the main concern is to relieve dying. However the conclusion
of this organisation is that there requires to be more detailed
consideration of the highly valued nursing roles that practise
within this domain of care.
House of Commons Health Committee (2004) Palliative
Care Fourth Report of Session 2003-2004, Volume One, London:
The Stationary Office Ltd.
Nursing and Midwifery Council (2004) The NMC Code
of Professional Conduct: standards for conduct, performance and
ethics, Nursing and Midwifery Council. www.who.org
20 August 2004