Memorandum by the Royal Marsden School
of Cancer Nursing and Rehabilitation
The Royal Marsden School of Cancer Nursing and
Rehabilitation, part of The Royal Marsden Hospital, is a provider
of specialist post registration cancer and palliative care education
to nurses and allied health professionals. The hospital has a
staff of 10 teachers all of whom have a nursing or rehabilitation
professional registration. All programmes are developed and delivered
in close collaboration with clinical colleagues within the trust.
This submission has been prepared by the Assistant Chief Nurse/Head
of School, Sara Lister and Lecturer Practitioner Palliative Care
Patricia Hunt, following discussion with Consultant in Palliative
Care Dr Julia Riley and the Chief Nurse/Deputy Chief Executive
Dr Dickon Weir Hughes. This submission has been reviewed by the
staff of the School and represents the majority of their views.
2. APPROACH TAKEN
This response will focus on what we consider
are the implications of the Bill from the perspective of post
registration nurse education:
3. ISSUES AND
3.1. If this became legislation all nurses
working in environments where the powers of this bill maybe enacted
would need to undertake education about the implications for nursing
practice and the role of the nurse if this circumstance arose.
This would obviously have considerable manpower and resource implications
in an environment where staffing is already very stretched and
the education and training agenda to meet the requirements of
clinical governance is already extensive. As a minimum a programme
would need to include the following content:
Exploration of the philosophy underpinning
the Assisted Dying Bill because this is in significant contrast
to the holistic approach underpinning palliative care. Currently
palliative nurse education programmes are designed around the
principles underpinning palliative care, which are defined by
the WHO (2004) as an approach that improves the quality of life
for patients with life-threatening illnesses and their families
by early identification, assessment and treatment of pain and
other physical, psychosocial and spiritual problems. The WHO (2004)
principles continue by expressing that palliative care affirms
life and regards dying as a normal process and intends neither
to hasten nor postpone death. In essence, the current palliative
care philosophy taught in palliative care programmes would need
to be reviewed as it is contradictory to the legislation within
A structured framework to enable
practitioners to explore their own values and beliefs in respect
of assisted dying and to be able to make a conscious decision
about the extent they would be involved if the situation arose.
Details of the alternative palliative
care provision available. If a patient has developed a therapeutic
relationship with the nurse directly involved in their care we
suggest that they may first explore these issues with that nurse.
Although specialists in palliative care are increasing in number
through out the country and will be available to attend a patient
to discuss palliative care, it is expected that the patient may
want to further discuss this with the nurses directly involved
in their care.
Legal background and standing of
Implications for their professional
practice of the Bill.
Spiritual perspectives of assisted
The practicalities of how a patient
will be assisted to die. (The Bill does not make this explicit)
If it is going to be through the administration of a drug, the
mode of delivery, the action of the drug, potential side effects
must be included. This will be necessary; as a patient will want
to know what will happen.
How to respond to a patient who expresses
a wish to die, the questions to ask and areas to explore.
3.2. It is estimated that as a minimum two
days would be required to cover the content.
3.3. If this legislation was introduced
a considerable amount of time in existing palliative care programmes
would need to be dedicated to this area of practice. This would
detract from the content dedicated to the holistic care of the
patient and family including symptom management, pain relief,
spiritual and psychosocial issues.
3.4. This Bill includes legislation to make
provision for pain relief for a person who is terminally ill.
Currently there are no legal restrictions to the prescription
of appropriate pain relief by a medical practitioner to a person
who needs it, so we don't know why this has been included. The
restriction to appropriate pain relief is often due to poor access
to appropriate palliative care facilities or lack of healthcare
professionals with the expertise to prescribe appropriately. We
suggest that the funding is increased to improve education for
pain management in the terminally ill. Appropriate education with
adequate funding is essential.
3.5. Section 3 suggests a choice between
Palliative care and assisted dying. The approach to palliative
care is a holistic one and begins at the point of diagnosis. It
is not a treatment option when the pain or symptoms get unbearable.
The philosophy of Palliative care is to be involved early in the
course of the disease, involving the patient and family so symptoms
and pain never become unbearable. Palliative care should be available
to an individual who chooses assisted death. This should not be
an either/or situation. From the education perspective it is essential
that the bill doesn't suggest this.
We oppose this legislation. We suggest that
the interests of dying patients and their families would be better
served by increasing the funding available for palliative care,
specifically improving the opportunities for healthcare professionals
to access appropriate education to enable them to develop the
competencies required to give patients effective palliative care.
WHO (2004) WHO Definition of Palliative Care
(Electronic Version) retrieved 20 August 2004 from http://www.who.int/cancer/palliative/definition/en/print.html