Pain management is always fraught. Photo: Getty
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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

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Leader: Trump and an age of disorder

Mr Trump’s disregard for domestic and international norms represents an unprecedented challenge to established institutions.

The US presidency has not always been held by men of distinction and honour, but Donald Trump is by some distance its least qualified occupant. The leader of the world’s sole superpower has no record of political or military service and is ignorant of foreign affairs. Throughout his campaign, he repeatedly showed himself to be a racist, a misogynist, a braggart and a narcissist.

The naive hope that Mr Trump’s victory would herald a great moderation was dispelled by his conduct during the transition. He compared his country’s intelligence services to those of Nazi Germany and repeatedly denied Russian interference in the election. He derided Nato as “obsolete” and predicted the demise of the European Union. He reaffirmed his commitment to dismantling Obamacare and to overturning Roe v Wade. He doled out jobs to white nationalists, protectionists and family members. He denounced US citizens for demonstrating against him. Asked whether he regretted any part of his vulgar campaign, he replied: “No, I won.”

Of all his predilections, Mr Trump’s affection for Vladimir Putin is perhaps the most troubling. When the 2012 Republican presidential nominee, Mitt Romney, warned that Russia was the “number one geopolitical foe” of the US, he was mocked by Barack Obama. Yet his remark proved prescient. Rather than regarding Mr Putin as a foe, however, Mr Trump fetes him as a friend. The Russian president aims to use the US president’s goodwill to secure the removal of American sanctions, recognition of Russia’s annexation of Crimea and respect for the murderous reign of the Syrian president, Bashar al-Assad. He has a worryingly high chance of success.

Whether or not Mr Trump has personal motives for his fealty (as a lurid security dossier alleges), he and Mr Putin share a political outlook. Both men desire a world in which “strongmen” are free to abuse their citizens’ human rights without fear of external rebuke. Mr Trump’s refusal to commit to Nato’s principle of collective defence provides Mr Putin with every incentive to pursue his expansionist desires. The historic achievement of peace and stability in eastern Europe is in danger.

As he seeks reconciliation with Russia, Mr Trump is simultaneously pursuing conflict with China. He broke with precedent by speaking on the telephone with the Taiwanese president, Tsai Ing-wen, and used Twitter to berate the Chinese government. Rex Tillerson, Mr Trump’s secretary of state nominee, has threatened an American blockade of the South China Sea islands.

Mr Trump’s disregard for domestic and international norms represents an unprecedented challenge to established institutions. The US constitution, with its separation of powers, was designed to restrain autocrats such as the new president. Yet, in addition to the White House, the Republicans also control Congress and two-thirds of governorships and state houses. Mr Trump’s first Supreme Court appointment will ensure a conservative judicial majority. The decline of established print titles and the growth of “fake news” weaken another source of accountability.

In these circumstances, there is a heightened responsibility on the US’s allies to challenge, rather than to indulge, Mr Trump. Angela Merkel’s warning that co-operation was conditional on his respect for liberal and democratic values was a model of the former. Michael Gove’s obsequious interview with Mr Trump was a dismal example of the latter.

Theresa May has rightly rebuked the president for his treatment of women and has toughened Britain’s stance against Russian revanchism. Yet, although the UK must maintain working relations with the US, she should not allow the prospect of a future trade deal to skew her attitude towards Mr Trump. Any agreement is years away and the president’s protectionist proclivities could yet thwart British hopes of a beneficial outcome.

The diplomatic and political conventions embodied by the “special relationship” have endured for more than seven decades. However, Mr Trump’s election may necessitate their demise. It was the belief that the UK must stand “shoulder to shoulder” with the US that led Tony Blair into the ruinous Iraq War. In this new age of disorder, Western leaders must avoid being willing accomplices to Mr Trump’s agenda. Intense scepticism, rather than sycophancy, should define their response.

This article first appeared in the 19 January 2016 issue of the New Statesman, The Trump era