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

Photo: Getty Images
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Why are boundary changes bad for Labour?

New boundaries, a smaller House of Commons and the shift to individual electoral registration all tilt the electoral battlefield further towards the Conservatives. Why?

The government has confirmed it will push ahead with plans to reduce the House of Commons to 600 seats from 650.  Why is that such bad news for the Labour Party? 

The damage is twofold. The switch to individual electoral registration will hurt Labour more than its rivals. . Constituency boundaries in Britain are drawn on registered electors, not by population - the average seat has around 70,000 voters but a population of 90,000, although there are significant variations within that. On the whole, at present, Labour MPs tend to have seats with fewer voters than their Conservative counterparts. These changes were halted by the Liberal Democrats in the coalition years but are now back on course.

The new, 600-member constituencies will all but eliminate those variations on mainland Britain, although the Isle of Wight, and the Scottish island constituencies will remain special cases. The net effect will be to reduce the number of Labour seats - and to make the remaining seats more marginal. (Of the 50 seats that would have been eradicated had the 2013 review taken place, 35 were held by Labour, including deputy leader Tom Watson's seat of West Bromwich East.)

Why will Labour seats become more marginal? For the most part, as seats expand, they will take on increasing numbers of suburban and rural voters, who tend to vote Conservative. The city of Leicester is a good example: currently the city sends three Labour MPs to Westminster, each with large majorities. Under boundary changes, all three could become more marginal as they take on more wards from the surrounding county. Liz Kendall's Leicester West seat is likely to have a particularly large influx of Tory voters, turning the seat - a Labour stronghold since 1945 - into a marginal. 

The pattern is fairly consistent throughout the United Kingdom - Labour safe seats either vanishing or becoming marginal or even Tory seats. On Merseyside, three seats - Frank Field's Birkenhead, a Labour seat since 1950, and two marginal Labour held seats, Wirral South and Wirral West - will become two: a safe Labour seat, and a safe Conservative seat on the Wirral. Lillian Greenwood, the Shadow Transport Secretary, would see her Nottingham seat take more of the Nottinghamshire countryside, becoming a Conservative-held marginal. 

The traffic - at least in the 2013 review - was not entirely one-way. Jane Ellison, the Tory MP for Battersea, would find herself fighting a seat with a notional Labour majority of just under 3,000, as opposed to her current majority of close to 8,000. 

But the net effect of the boundary review and the shrinking of the size of the House of Commons would be to the advantage of the Conservatives. If the 2015 election had been held using the 2013 boundaries, the Tories would have a majority of 22 – and Labour would have just 216 seats against 232 now.

It may be, however, that Labour dodges a bullet – because while the boundary changes would have given the Conservatives a bigger majority, they would have significantly fewer MPs – down to 311 from 330, a loss of 19 members of Parliament. Although the whips are attempting to steady the nerves of backbenchers about the potential loss of their seats, that the number of Conservative MPs who face involuntary retirement due to boundary changes is bigger than the party’s parliamentary majority may force a U-Turn.

That said, Labour’s relatively weak electoral showing may calm jittery Tory MPs. Two months into Ed Miliband’s leadership, Labour averaged 39 per cent in the polls. They got 31 per cent of the vote in 2015. Two months into Tony Blair’s leadership, Labour were on 53 per cent of the vote. They got 43 per cent of the vote. A month and a half into Jeremy Corbyn’s leadership, Labour is on 31 per cent of the vote.  A Blair-style drop of ten points would see the Tories net 388 seats under the new boundaries, with Labour on 131. A smaller Miliband-style drop would give the Conservatives 364, and leave Labour with 153 MPs.  

On Labour’s current trajectory, Tory MPs who lose out due to boundary changes may feel comfortable in their chances of picking up a seat elsewhere. 

Stephen Bush is editor of the Staggers, the New Statesman’s political blog. He usually writes about politics.