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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How Theresa May laid a trap for herself on the immigration target

When Home Secretary, she insisted on keeping foreign students in the figures – causing a headache for herself today.

When Home Secretary, Theresa May insisted that foreign students should continue to be counted in the overall immigration figures. Some cabinet colleagues, including then Business Secretary Vince Cable and Chancellor George Osborne wanted to reverse this. It was economically illiterate. Current ministers, like the Foreign Secretary Boris Johnson, Chancellor Philip Hammond and Home Secretary Amber Rudd, also want foreign students exempted from the total.

David Cameron’s government aimed to cut immigration figures – including overseas students in that aim meant trying to limit one of the UK’s crucial financial resources. They are worth £25bn to the UK economy, and their fees make up 14 per cent of total university income. And the impact is not just financial – welcoming foreign students is diplomatically and culturally key to Britain’s reputation and its relationship with the rest of the world too. Even more important now Brexit is on its way.

But they stayed in the figures – a situation that, along with counterproductive visa restrictions also introduced by May’s old department, put a lot of foreign students off studying here. For example, there has been a 44 per cent decrease in the number of Indian students coming to Britain to study in the last five years.

Now May’s stubbornness on the migration figures appears to have caught up with her. The Times has revealed that the Prime Minister is ready to “soften her longstanding opposition to taking foreign students out of immigration totals”. It reports that she will offer to change the way the numbers are calculated.

Why the u-turn? No 10 says the concession is to ensure the Higher and Research Bill, key university legislation, can pass due to a Lords amendment urging the government not to count students as “long-term migrants” for “public policy purposes”.

But it will also be a factor in May’s manifesto pledge (and continuation of Cameron’s promise) to cut immigration to the “tens of thousands”. Until today, ministers had been unclear about whether this would be in the manifesto.

Now her u-turn on student figures is being seized upon by opposition parties as “massaging” the migration figures to meet her target. An accusation for which May only has herself, and her steadfast politicising of immigration, to blame.

Anoosh Chakelian is senior writer at the New Statesman.

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