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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Forget gaining £350m a week, Brexit would cost the UK £300m a week

Figures from the government's own Office for Budget Responsibility reveal the negative economic impact Brexit would have. 

Even now, there are some who persist in claiming that Boris Johnson's use of the £350m a week figure was accurate. The UK's gross, as opposed to net EU contribution, is precisely this large, they say. Yet this ignores that Britain's annual rebate (which reduced its overall 2016 contribution to £252m a week) is not "returned" by Brussels but, rather, never leaves Britain to begin with. 

Then there is the £4.1bn that the government received from the EU in public funding, and the £1.5bn allocated directly to British organisations. Fine, the Leavers say, the latter could be better managed by the UK after Brexit (with more for the NHS and less for agriculture).

But this entire discussion ignores that EU withdrawal is set to leave the UK with less, rather than more, to spend. As Carl Emmerson, the deputy director of the Institute for Fiscal Studies, notes in a letter in today's Times: "The bigger picture is that the forecast health of the public finances was downgraded by £15bn per year - or almost £300m per week - as a direct result of the Brexit vote. Not only will we not regain control of £350m weekly as a result of Brexit, we are likely to make a net fiscal loss from it. Those are the numbers and forecasts which the government has adopted. It is perhaps surprising that members of the government are suggesting rather different figures."

The Office for Budget Responsibility forecasts, to which Emmerson refers, are shown below (the £15bn figure appearing in the 2020/21 column).

Some on the right contend that a blitz of tax cuts and deregulation following Brexit would unleash  higher growth. But aside from the deleterious economic and social consequences that could result, there is, as I noted yesterday, no majority in parliament or in the country for this course. 

George Eaton is political editor of the New Statesman.