Last time I wrote about dying at home, it was my personal view of my grandmothers' euthanasia in Holland.1 I have now been involved in a similar situation, a death from cancer in Britain — and I was not impressed. This time it was not a relative but a friend — an 88-year-old gentleman who died of lung cancer. I am a general practitioner in another city. I watched things unfold; I wanted to be there for him and not get involved.
I visited him in hospital, walking assertively onto the ward outside visiting hours. He was discharged on a Friday and told the Macmillan nurses would contact him on Monday. He was short of breath at rest, but talking in sentences, mobile, and eating small meals. His pleural effusion had been drained and pleurodesis attempted. He had been a very active man, walking miles a day with the dog until 6 weeks before admission. At home he lived with his 84-year-old wife. The family managed to arrange oxygen and sleeping tablets on Friday afternoon from his GP surgery; he had been comfortable on these in hospital. They were not supplied with his discharge (there was a note about not supplying sleeping tablets long term). He deteriorated quickly, became more breathless, stopped eating, and became bed bound. His wife had difficulty getting him to the toilet and this was a problem at night when they were home alone. The Macmillan nurse arrived on Wednesday, by which time the family was angry and had verbally complained about this delay. He was put on oramorph as required, and the social worker came the same day and arranged a night sitter. These nice ladies were not nurses and could come for 5 nights only. They could not administer oral medication. They did, however, agree to give morphine if his wife had drawn it up in advance but did not seem that confident about knowing when to give it. By Thursday, my friend had called out his GP and asked him to end it all with an injection. Like my grandmother, he was losing his dignity and didn't want to go on anymore. His GP asked him if he was afraid to die, but with this remark the doctor missed the point. My friend wanted to die at that time and not suffer anymore. He was prescribed oral diazepam. I told him he knew euthanasia was illegal, but I would do my utmost to decrease his suffering. One Saturday I turned up early to find him breathless, exhausted and in distress. I gave him oramorph and diazepam (he had not had any since 10 o'clock the previous night) and he fell into a peaceful sleep. His wife told me she wished he'd sleep like that until he died. I rang the district nurses, and suggested a syringe driver because he was becoming unable to take oral medication and needed 24 hour symptom relief. Due to a shortage of diamorphine, a low dose fentanyl patch was tried. This takes a long time to work and he was to be given oral morphine until it did work. By Sunday morning he could barely take anything orally and again I asked for a syringe driver. Now there was diamorphine. The only problem was that the hospice had suggested 10 mg diamorphine over 24 hours with the patch, and the on call doctor prescribed 20 mg. The district nurse would not give my friend this dose and it took her 3 more hours to get the right dose. She was worried about suppressing his respiration, something the relatives by that stage could not understand. By 2 p.m. the syringe driver was up and at last my friend was comfortable. He died peacefully that night.
What shocked me was how much I had to become involved. I wanted to watch him die peacefully at home with good palliative care. If you won't allow euthanasia, please give people a good alternative.
- © British Journal of General Practice, 2005.
