European Network of Health Care Chaplaincy
NHS Education for Scotland, Chaplaincy Training and Development Unit
Scotland
1. The legal regulations on end of life choices in the UK
Any purposeful activity by a third party with the intention of hastening death or shortening life through direct action or the provision of the means for the patient to do so is illegal in the UK. Therefore, both euthanasia and ‘physician assisted suicide’ are prohibited. However, those involved in ‘mercy killing’ either by providing the means by which a dying or suffering patient kills themselves or actively killing another in such circumstances is usually dealt with leniently by the Scottish Legal system.
The withdrawal, cessation or non initiation of possible treatment either at the patient’s request or, when the patient is unable to make such a decision, by the doctor in charge of their care (in discussion with the patient’s family and/or next of kin), acting in the patient’s best interest, in appropriate cases is considered best practice.
2. The view of the churches in Scotland on end of life choices?
The official view of the larger denominations (Church of Scotland, Roman Catholic and Episcopalian/Anglican) in Scotland would concur with current legislation. All that palliative care involves is strongly supported by Scottish churches – enabling patients to live life as fully as possible up until death. However, the opinion of individuals within the churches in Scotland varies greatly and some may see hastening a patient’s death in certain circumstances as a compassionate and merciful act.
3. The main tensions in the chaplains’ general practice concerning quality of end of life?
a) Allocation of resources and issues of injustice/non-availability of certain types of specialist treatment or surgery.
eg. awaiting organ donation and who is or is not deserving of donation — issues of lifestyle or ‘self-inflicted’ harm (overdose, alcoholism, IV drug habit etc).
Difficulties caused by the need to triage resources/ethical questions re who is ‘most deserving’ of specialist equipment/drugs/care eg ventilation when number of intensive care beds may be limited.
A recognition that in the acute and primary settings we have many things to achieve before we can claim to offer a similar end of life experience as to that which is often achieved in a hospice setting (true for patient/carer/staff) e.g. environment, pain control, lack of availability of spiritual care especially specialist spiritual care/lack of understanding of role of spiritual care specialist leading to opportunities for support being missed.
b) Questions around DNAR policies, support for patients and families, support for staff, who adjudicates when there are significant differences of opinion? (need for individual solutions within an overall agreed culture of care)
c) Supporting patients, relatives/close friends and staff as they work through whether a patient should start, accept, continue with or cessate certain treatment/supportive options
eg – surgery/chemotherapy or not in later stages of cancer, introducing PEG feeding for some stroke sufferers who have difficulty swallowing or withdrawal of life support perhaps particularly when there has been a sudden onset of illness.
d) Supporting staff, families and sometimes patients when end of life decision making has not been as collaborative as they wished or the decision taken is contrary to their or indeed the chaplain’s opinion. Sometimes chaplain acting as an advocate for one of these parties during the decision making process when chaplain feels a certain party has not been heard, does not understand what has been said or the implications of certain actions or a party been overlooked altogether.
e) Supporting patients, families and staff in decision making process as to whether best for a patient and/or relatives and staff (if staff are being honest) if the patient is sedated in terminal phase of life to reduce pain and agitation for patient and reduce anxiety for relatives and staff.
f) Difficulties of waiting for a patient to die and supporting patient, staff and relatives on a prolonged ongoing basis, especially if any of the parties (including the chaplain) feels extremely helpless and wants the process to be speeded up. ‘You wouldn’t let a dog die like this.’
g) Having to support individuals and their family or close friends following poor communication about their condition, during decision making or after death. Perhaps also having to convey to colleagues the implications of their poor communication.
For example, patients and relatives being given a timescale by a healthcare professional for the dying process and death, and death not coming when anticipated.
h) Patients and families not being given adequate opportunity by healthcare professionals, where possible, to talk about end of life issues and choices early in the patient’s disease pathway. Therefore, when crisis occurs or death is imminent the individual or family concerned may be ill prepared to make difficult decisions or indeed contemplate dying, death and bereavement.
i) Chaplains feeling ‘ I’ve got things wrong’, are emotionally drained or have been theologically or ethically challenged by involvement in end of life care/issues and having a means by which we can debrief, unload and reflect on and learn from practice.
j) Occasionally tensions which are faith specific eg refusal of certain life saving treatments.
k) Supporting a patient, relatives and staff (and ensuring support for self) when a patient who is not clinically depressed has declared suicidal intent due to prolonged suffering and total lack of meaning and purpose in life.
4 December 2009
1. What are the legal regulations on end of life choices in your country?
2. What is the view of your church (or the churches you represent) in your country on end of life choices?
3. What are the main tensions in the chaplains’ general practice concerning quality of end of life?
Report on End of Life Issues by the Church and Society Council
of the Church of Scotland (May 2009)