Pain management is always fraught. Photo: Getty
Show Hide image

Jill thought she knew best for her father so she kept the morphine coming

Whatever her motivations – and whether she had even been aware of them – she had been hastening his demise.

The call came on Sunday evening, flagged as urgent on the computer. I rang the home number, which was answered by a woman.

“My father is dying of prostate cancer with bony mets,” she explained. “He’s in a lot of pain.”

The medical terminology struck me. “Are you in health care?”

“I’m a nurse. I don’t mean to tell you your job, but I think it’s time for a syringe driver.”

As death approaches, medication taken by mouth can become unreliable. In order to control symptoms, drugs are administered subcutaneously by a device known as a syringe driver. The siting of a driver often heralds the final hours of life. As well as relieving pain and mental distress, the potent drugs used can depress consciousness and respiration, which more often than not hastens the end. This is not euthanasia: it is permissible as the price of effective palliation, the “doctrine of double effect”.

When I arrived at the house, Frank was alone with his daughter, Jill, a neatly dressed woman in her forties who had travelled down from her Northumberland home to nurse him in his final illness. She described how, no matter how much morphine she gave, she didn’t seem able to control his pain. Frank was indeed in a bad way – semi-conscious, markedly confused and rambling – but he didn’t appear objectively to be suffering. There was one brief moment when he did wince. Jill responded instantaneously, spooning in a dose of liquid morphine as a parent might feed a baby.

“How much has he been having?” I asked.

Jill shrugged. “I give him some every time he’s in pain.”

When working out of hours, one has no access to patients’ records – all information has to be gained first-hand. I asked to see the rest of Frank’s medication. In the depths of a laden carrier bag I found plenty of paracetamol and diclofenac, an anti-inflammatory.

“Is he having these?” I asked.

“Oh, no, he’s just on morphine now,” she replied.

Bone pain doesn’t generally respond to morphine alone. One usually prescribes anti-inflammatories and paracetamol; these potentiate the effect of morphine, allowing far less opiate to be used.

I wrote out a schedule, specifying regular doses of the two abandoned drugs, and insisting that Jill note down every dose of morphine given.

It had all taken a long time. Leaving, I bumped into two other women coming in at the gate. They turned out to be Frank’s elderly wife with another daughter. I’d had no idea there was a spouse around. She seemed equally bewildered to meet me, saying that her daughter had taken her out for an evening drive. It was midwinter, and dark outside.

The overdosing on morphine was one thing; quite another was the removal of Frank’s wife before calling the doctor in. Safeguarding children is a familiar concept, but in recent years there’s been a growing realisation that adults are sometimes in need of protection, too. I contacted Frank’s GP first thing in the morning and he convened an urgent safeguarding conference. A troubling picture emerged. Frank’s four children had a lifelong history of rivalry, division and competition for paternal attention. Jill and her sister were allies against the other two, and against their mother. The wider family reported that Jill had descended on the home, taking control of Frank’s treatment and shutting the others out, pulling rank by virtue of her spell in nursing some 15 years earlier.

The conference prohibited Jill from further direct involvement in her father’s care. Treatment optimised, Frank came off virtually all morphine. His confusion resolved completely, and he had another five months of good-quality life. Whatever her motivations – and whether she had even been aware of them – Jill had been hastening his demise. How easy it would have been for an out-of-hours doctor unwittingly to have colluded, taking things at face value and acceding to Jill’s suggestion that the time for a syringe driver was nigh.

This article first appeared in the 16 July 2015 issue of the New Statesman, The Motherhood Trap

Photo: Getty
Show Hide image

Scotland's vast deficit remains an obstacle to independence

Though the country's financial position has improved, independence would still risk severe austerity. 

For the SNP, the annual Scottish public spending figures bring good and bad news. The good news, such as it is, is that Scotland's deficit fell by £1.3bn in 2016/17. The bad news is that it remains £13.3bn or 8.3 per cent of GDP – three times the UK figure of 2.4 per cent (£46.2bn) and vastly higher than the white paper's worst case scenario of £5.5bn. 

These figures, it's important to note, include Scotland's geographic share of North Sea oil and gas revenue. The "oil bonus" that the SNP once boasted of has withered since the collapse in commodity prices. Though revenue rose from £56m the previous year to £208m, this remains a fraction of the £8bn recorded in 2011/12. Total public sector revenue was £312 per person below the UK average, while expenditure was £1,437 higher. Though the SNP is playing down the figures as "a snapshot", the white paper unambiguously stated: "GERS [Government Expenditure and Revenue Scotland] is the authoritative publication on Scotland’s public finances". 

As before, Nicola Sturgeon has warned of the threat posed by Brexit to the Scottish economy. But the country's black hole means the risks of independence remain immense. As a new state, Scotland would be forced to pay a premium on its debt, resulting in an even greater fiscal gap. Were it to use the pound without permission, with no independent central bank and no lender of last resort, borrowing costs would rise still further. To offset a Greek-style crisis, Scotland would be forced to impose dramatic austerity. 

Sturgeon is undoubtedly right to warn of the risks of Brexit (particularly of the "hard" variety). But for a large number of Scots, this is merely cause to avoid the added turmoil of independence. Though eventual EU membership would benefit Scotland, its UK trade is worth four times as much as that with Europe. 

Of course, for a true nationalist, economics is irrelevant. Independence is a good in itself and sovereignty always trumps prosperity (a point on which Scottish nationalists align with English Brexiteers). But if Scotland is to ever depart the UK, the SNP will need to win over pragmatists, too. In that quest, Scotland's deficit remains a vast obstacle. 

George Eaton is political editor of the New Statesman.