Christian doctors call for ban on NHS 'bribing' hospitals to put more patients on controversial death pathway

The Daily Mail has today run a story highlighting Christian Medical Fellowship’s suggestions on how the implementation of the controversial Liverpool Care Pathway could be improved.

The LCP is a framework for the care of patients in the last hours or days of life that is now used in the management of about one third of all dying patients in Britain.

The government is currently carrying out an investigation into its use and it is also the subject of a parliamentary debate on Tuesday 8 January.

I have blogged about the LCP extensively (see links here and latest update here)

The Daily Mail has used a dramatic headline (‘Christian doctors call for ban on NHS “bribing” hospitals to put more patients on controversial death pathway’) including the word ‘bribing’ which we did not use, but they have helpfully highlighted a number of our concerns.

The full CMF press release, my most recent blog and a recent Triple Helix article by Dr Jeff Stephenson are all available on line for those who would like to read our nine recommendations in full.

The Daily Mail has majored on the 7th of these which was worded as follows:

'Non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated and every patient treated solely according to their need. In this connection it would be far better to link CQUIN payments to staff training in the use of the pathway rather than numbers of patients placed on the pathway.'

The Daily Mail’s most salient quotes are as follows:

An influential group of Christian doctors yesterday called for an end to financial ‘bribes’ that encourage hospitals to place dying patients on the controversial Liverpool Care Pathway.

The Christian Medical Fellowship said judgments about whether to withdraw treatment from terminally-ill patients should be made solely on clinical grounds.

The CMF, which represents more than 4,000 doctors, said financial incentives for hospitals to use the system – thought to run at more than £10 million a year in total – should be ‘eradicated’ immediately.

It also urged ministers to tighten controls to end the ‘undoubted abuses’ of a system designed to ensure patients die with dignity.

Dr Jeff Stephenson, a Devon-based consultant in palliative care, said the care pathway could help ease suffering if used properly.

But he added: ‘It remains a tool, and it is only as good as those who use it. There is always potential for misuse and abuse and there are undoubtedly instances where this occurs.

‘Where these arise by intention then those involved should be held to account, but more often they occur through poor understanding and inadequate training.

‘We owe it to patients to not only furnish the means to better care, but also to equip adequately those who provide it.’

Payments to hospitals to introduce it are made through a system called Commissioning for Quality and Innovation, which channels money to hospital trusts through NHS ‘commissioners’.

…the CMF said a number of urgent steps were needed to restore public confidence in a system used in around 130,000 cases a year.

Hospitals are thought to have been rewarded with an extra £30million over the past three years for increasing their use of the LCP.

The CMF said these payments should be ended, with the cash diverted into better training for staff.

It said: ‘Non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated and every patient treated solely according to their need.’

The organisation also said no patient should be placed on the LCP unless they were ‘imminently dying’.

Assessments should only be made by senior doctors and the decision should be discussed with patients and their families.

Anyone placed on the pathway who shows signs of improvement should be taken off it immediately.

…The CMF also called for an annual audit of the care pathway to ensure it is being used properly.

Cases of abuse should be reported to the appropriate medical body, such as the General Medical Council, for possible disciplinary action.

Liverpool Care Pathway – nine points for the government to consider in its review

Secretary of State for Health, Jeremy Hunt (pictured), yesterday hailed the controversial Liverpool Care Pathway (LCP) for patients who are dying as ‘a fantastic step forward’ in the way hospitals support the terminally ill.

I agree that the LCP is a useful clinical tool that has helped many thousands of people experience better care in the last hours or days of life, but like any tool it must be used with the proper indications and by properly trained staff.

Every airline accident should make our next air trip safer; in the same way every abuse or misuse of the LCP should mean that the same mistake never occurs again.

CMF has recently called on the government to consider nine key points in its recently announced review of the LCP which is currently used with around 130,000 people a year, about a third of annual deaths in the UK.

To iron out the abuses that have been reported, several key measures need to be implemented:

1.It should be made absolutely clear that no one who is not imminently dying within hours, or at most two or three days, should be placed on the LCP and anyone placed on it who shows improvement should be taken off it. These assessments should be made by senior clinicians.

2.No one should be placed on the LCP without it being discussed with the relative or carer (although the latter do not need to give consent).

3.Every patient placed on the LCP must be regularly monitored and reassessed by a multidisciplinary team.

4.The present documentation is far too complex and needs to be simplified and standardised so that those implementing it can easily follow the guidelines and supervisors can easily tell what is going on with each patient.

5.Training and supervision of those using the pathway needs to be standardised and improved and formal training should be required before any healthcare professional is able to use it.

6.An annual audit needs to be carried out and all suboptimal use identified promptly acted upon.

7.Non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated and every patient treated solely according to their need. In this connection it would be far better to link CQUIN payments to staff training in the use of the pathway rather than numbers of patients placed on the pathway.

8.Communication to relatives both by health professionals and organisations involved in LCP implementation needs to be substantially improved.

9.Those misusing the LCP should be quickly identified and in the case of abuse reported to the appropriate authorities (General Medical Council, Nurses and Midwifery Council or Health and Care Professions Council).

Writing in a recent review for CMF’s journal Triple Helix, Dr Jeff Stephenson, a Devon-based consultant in palliative care has said:

‘The LCP represents a pragmatic and effective response to some of the suffering experienced by many in the last days of life. It remains, however, a tool and it is only as good as those who use it. There is always potential for misuse and abuse and there are undoubtedly instances where this occurs. Where these arise by intention then those involved should be held to account, but more often they occur through poor understanding and inadequate training. We owe it to patients to not only furnish the means to better care, but also to equip adequately those who provide it.’

Stephenson’s whole article is well worthy of study.

‘Death Lists’ – how unbalanced reporting can damage a well-intentioned initiative to improve care

In the last two days the Daily Mail has run two articles with the following alarmist headlines:

Put 1 in 100 patients on death list, GPs told: Frailest to be asked to choose 'end-of-life' care

3,000 doctors putting patients on 'death lists' that single them out to be allowed to die

The articles draw attention to a new campaign aimed at helping GPs to identify patients nearing the end of life in order to improve their care.

The ‘Find Your 1% campaign’ is funded by the Quality, Innovation, Productivity, and Prevention End of Life Care workstream (QIPP) and is being hosted by the Dying Matters Coalition.

It is supported by the Royal College of General Practitioners (RCGP) and the National End of Life Care Programme (NEoLCP).

‘Find your 1%’ is based on the idea that around 1% of a GP’s patients will die in any given year and it aims to help GPs identify those patients who have a year or less to live in order to improve their care.

Currently around 70% of people want to die at home, yet more than half of the 450,000 people who die each year in England do so in hospital.

As well as improving patient care the scheme, it is said, would also save the NHS money as there would be fewer inappropriate emergency hospital admissions.

Typically towards the end of life, each unplanned admission to hospital costs more than £3,000. In the last 12 months before death, patients average 3.5 admissions each, with estimates that at any one time 20% of all hospital beds are occupied by people who are dying. If each person had one less crisis admission, the NHS would save £1,350,000,000 (NHS QIPP EOL workstream 2010).

I was phoned by the Daily Mail yesterday and asked to comment on the campaign, which I did, but unfortunately I was quoted selectively in a way that made it look like I was criticising it, when I was not intending to do so at all.

The sentences they extracted from my interview, which I asked to see and approved, read as follows:

‘If GPs are being encouraged to identify those patients who are terminally ill in order that they can be provided with the best care that is to be applauded. However I think we have to be very careful with the process of quotas. It is essential that every single case is reviewed on its own merits and the decision is made in a fully evidence-based way.

‘We all know that doctors’ estimates of patients’ lifespans can be sometimes accurate but sometimes wildly inaccurate. Caution needs to be exercised in making predictions. We all remember the cases of Al Megrahi and Ronnie Biggs. A skilled doctor can in the great majority of cases assess when a patient is within a few hours or days of death. However, once we start to talk about weeks or months we know that we can often be right, but equally very badly wrong. That is why it is so important that any assessment like this is regularly reviewed in the light of new evidence.'

‘This also goes for the Liverpool Care Pathway, where we know that some people have been put on it inappropriately.’

When it ran the article however, the Daily Mail excluded my first sentence, where I applauded the general principle of identifying terminally ill patients with the purpose of providing better care, extracted only the word ‘quotas’ from my second sentence, ran the bulk of the sentences on the difficulties of assessing lifespans and reframed my comments about some patients being inappropriately being placed on the Liverpool Care Pathway to make it appear that I was criticising the pathway per se.

They were, in other words, attempting to make my comments support an editorial agenda.

Anyone who reads my blogs knows that I am firmly opposed to assisted suicide, euthanasia and legally binding advance refusals for food and fluids. Intentional killing by act or omission is always wrong.

I am also very wary of government-led agendas driven by the desire to cut costs as opposed to delivering better care. Patients should not be deprived of helpful treatments.

But equally, dying is actually a normal part of life and should not be over-medicalised.

Unnecessary emergency hospital admissions and intrusive burdensome interventions for dying patients who could be managed more effectively by GPs at home can be traumatic and damaging.

It is important that patients can access the care they need at the end of life and that they are helped to die comfortably in the place of their choosing. Any campaign that helps GPs provide better care for dying patients is therefore to be welcomed.

I see that Dying Matters Chief Executive Eve Richardson and National End of Life Care Programme Director Claire Henry have responded to the Daily Mail with the letter below, with which I concur.

Dear Sir,

Far from being placed on a ‘death list’ as your article misleadingly suggests ('Put 1 in 100 patients on death list, GPs told', 17 October 2012), it is crucially important that GPs talk sensitively to people in their practice who are coming towards the end of their life about their wishes, such as whether they want to be cared for in their own home rather than in hospital.

After all, half a million people in England die every year, but many people aren't getting the end of life care that they need, often because their wishes have not been discussed with them. After loved ones, people tell us it is their GPs they want to turn to for information and support about planning for their end of life wishes.

Eve Richardson, Chief Executive, Dying Matters Coalition
Claire Henry, Director, National End of Life Care Programme

Another poll from the Voluntary Euthanasia Society (aka DID) to grab headlines ahead of new moves to legalise assisted suicide

The Voluntary Euthanasia Society, which renamed itself ‘Dignity in Dying’ in 2006 to disguise its real agenda, has commissioned yet another poll to bolster support for its tired ongoing campaign to legalise assisted suicide.

Having failed on three occasions in the last few years to convince Parliament to change the law DID is now trying to soften up public opinion ahead of a fresh assault on our legislature this autumn. It is now targeting Scotland, Westminster and the Isle of Man (more on that later).

When I heard this morning from the Press Association that DID was about to publish another opinion poll showing support for its position – I wondered what possible excuse they could have come up with this time for playing the same old stuck record. But apparently tomorrow, 3 August, is the 50th anniversary of the Suicide Act 1961 which decriminalised suicide but left assisted suicide as a crime carrying a discretionary custodial sentence of up to 14 years.

The poll shows that three out four people think assisted suicide should be available for terminally ill people but only one in three think it should be available for disabled people.

The pro-euthanasia lobby have commissioned this latest survey to bolster support for their campaign to make assisted suicide legal for people who are terminally ill but they have so far failed to come up with precise definitions of ‘terminally ill’ or ‘disabled’ that have satisfied decision-makers and legislators. Disabled people and terminally ill people are not distinct groups – many disabled people are terminally ill and many terminally ill people are disabled.

Parliament, the medical profession and all of the leading disability rights groups in Britain have consistently opposed any change in the law to allow assisted suicide or euthanasia for any group at all on grounds of public safety, believing that any such a change would inevitably place pressure on vulnerable people to end their lives and expose them to exploitation and abuse by those with an interest, financial or otherwise, in their deaths.

DID desperately want to get the camel’s nose into the tent by establishing a beach-head for assisted suicide initially for a small group of people but we should recognize that there is a lot more camel to follow.

This survey should be seen for what it is, a ploy aimed at shoring up support for Charlie Falconer’s discredited and flagging ‘Commission on Assisted Dying’, manned and funded by assisted suicide advocates and exposed as a bent jury by the BMA, which is due to report later this year and is expected to recommend changing the law to allow ‘terminally ill, mentally competent adults’ to have their lives ended on request.

It will be interesting to see if DID publish the actual questions they asked. It is not their usual practice, but if not I will post them on this blog later this week along with an explanation of what they really mean once you strip away the specious euphemisms.

Two women in their 50s with serious brain damage whose relatives want them dead. One judge has said ‘yes’ but the other is still thinking. Why?

Two cases of women in their 50s with serious brain damage went before the courts this week.

Neither patient is dying, but both require 24 hour nursing care and are fed via by a tube. In both cases applications have been made to have hydration and nutrition withdrawn in order than they might die from dehydration and/or starvation.

In the first case the judge has already given the go-ahead to end the patient’s life. But in the second case, that involving a woman in the North of England referred to as ‘M’, which finishes its hearing on Monday, we will have to wait until 23 September for the judgement.

Why the difference? Well, it all relates to a subtle difference in diagnosis and the state of the law in Britain.

The first patient is in ‘permanent vegetative state’ (PVS), which means that she has been judged to have no awareness for over a year. Since the Bland ruling in 1993, it has been possible to apply to the High Court to have nutrition and hydration withdrawn from people with this condition. This woman will be the 44th such patient to die in this way after a court ruling.

The second woman, M, is in a ‘minimally conscious state’ (MCS), the next step up from PVS. In other words, she has some very limited awareness. Thus far, no court has ruled that such a patient can be starved and dehydrated to death. But the woman’s partner and sister nevertheless wish to go down this route.

The legal principles established in the Tony Bland case (pictured), who developed PVS following the Hillsborough disaster, were given statutory force in the Mental Capacity Act 2005, and apply in subsequent PVS cases. And they have not been overturned by the Human Rights Act.

Each case, however, is still required to go to court.

The Nursing Times this week ran the Press Association’s account of the first case referred to above (the PVS case), which I reproduce here:

The High Court has given a health trust permission to lawfully withdraw life-sustaining treatment from a woman in a permanent vegetative state.

Mr Justice Charles, sitting at the Court of Protection in London, ruled that stopping artificial nutrition and hydration would be in the best interests of the 54-year-old mother of four.

Members of her family, who the court heard were ‘entirely supportive’ of the application made by the trust responsible for her care, were present in court for the decision.

Following a ‘collapse’ in 2009, the woman, who cannot be identified for legal reasons, suffered ‘extensive hypoxic brain damage’.

The judge said the application by a NHS trust, which also cannot be named, was for a declaration ‘to render lawful’ the withdrawal of hydration, nutrition and medication for a heart condition.

He said: ‘The consequence of that is that very sadly the patient will die.’

The judge said he was ‘satisfied that appropriate testing and observations have been carried out by the appropriate qualified professionals’ over a significant period of time.

There was ‘convincing evidence from those who are nearest and dearest to her that there is nothing in her approach to life which would indicate that, if she were able to say something about it, she would not completely support what the family are asking me to do’.

He concluded: ‘In my judgment this patient has permanent extensive brain damage and is in a permanent vegetative state. Further treatment would be futile.’ The declaration sought was ‘in her best interests’.

At the time of the Bland case Christian Medical Fellowship expressed serious misgivings about that judgment which we felt crossed a legal rubicon. Three of the reasons for our concern feature in the above account; three concepts embodied in the terms ‘in her best interests’ and ‘further treatment would be futile’.

These terms embrace three important legal precedents established by Bland.

The first precedent is that nutrition and hydration constitute treatment. Our argument was that they constitute rather basic human needs that all of us share. Treatments are aimed at reducing or reversing the effects of an illness. But hydration and nutrition, like air, are simply essential requirements for life. Withdrawing all nutrition and hydration from any human being will result in death. But withdrawing a treatment will only result in the deaths of those who rely on that treatment to stay alive.

The second precedent is that having one’s life actively ended, when one is not actually dying, can be in a person’s best interests. But that is a philosophical position based on a particular world view. We can only make a judgment that death is in a person’s best interests by starting with a set of presuppositions about the nature of life, suffering, morality and death that lead to that conclusion. Our argument was that we have no right to decide what another person’s best interests are. Or alternatively that if we are in any doubt, then the benefit of the doubt should be in the direction of preserving life. Deciding for another person that it is in their best interests to have their life ended is a very dangerous precedent indeed. Especially if that person is unable to express an opinion on the matter.

The third precedent is that providing basic care to a person with PVS would be futile. But nutrition and hydration has a real and measurable effect in that it stops a patient dying from dehydration and/or starvation. So how is it futile? It can only be so if a patient’s continued existence itself is judged to be futile. Our argument was that whilst doctors are justified in deciding whether or not a treatment was futile – in that it had no measurable effect or imposed burdens disproportionate to any benefit – they have no right to make judgments about whether a patient’s life is futile.

The assumptions that nutrition and hydration constitute treatment rater than care, that being starved and dehydrated to death can be in a person’s best interests and that the lives of some people are futile are all false assumptions. They should never have been given legal force. But sadly they have.

The Bland judgment was seriously flawed. Bland and the 43 others who have died after him, including the case this week, should not have died in this way. They should have been given basic care, including nutrition and hydration, until they died naturally.

But if the judge presiding over the case of M, the second woman (with MCS), were to decide on 23 September to ‘pull the plug’ an even greater wrong would be done which would place the lives of many disabled people in danger by the legal precedents it created. What we should be doing instead is trying to overturn the Bland decision and amend the Mental Capacity Act.

Whilst the Mental Capacity Act was being drawn up in 2004-5 the Voluntary Euthanasia Society (renamed ‘Dignity in Dying’ in January 2006) took a huge interest and made a significant contribution to its wording. The concepts of ‘futile life’, ‘best interests’ being served by having one’s life ended and nutrition and hydration constituting treatment were all ideas they supported.

They wanted to pave the way to enable people whose lives were judged to be ‘futile’ to be starved and dehydrated to death. Why?

Well we have to go back a little in history to look at the agenda the international ‘pro-euthanasia movement have been pursuing for decades.

At the Fifth Biennial Conference of the World Federation of Right to Die Societies held in Nice, France on 20-23 September 1984, Helga Kuhse, PhD, lecturer in philosophy at Monash University and Research Fellow at the Centre for Human Bio-Ethics in Melbourne, Australia, made the following statement:

‘If we can get people to accept the removal of all treatment and care – especially the removal of food and fluids – they will see what a painful way this is to die, and then, in the patient’s best interests, they will accept the lethal injection.’

There’s that term ‘best interests’ again.

Kuhse is not proposing a policy of coercive ‘voluntary euthanasia’. Her view is that a public policy, which allows the withholding of food and fluids, is a cruel one and not in the patient’s best interest. She believes the public recognition that such a policy grossly disregards the interests of patients must eventually lead to the acceptance of active euthanasia.

You don’t often hear this worded as bluntly these days by advocates of legalising euthanasia. They also deny supporting euthanasia for people who are not mentally competent. But the agenda is still there. Allowing death by dehydration and starvation is a step aimed at softening up the public for the introduction eventually of involuntary euthanasia – in their ‘best interests’.

Italy joins Bulgaria and France in blocking euthanasia legislation as new withdrawal of treatment case is about to be heard in Britain

Earlier this year I reported that France, Australia, Scotland, Israel and Canada had recently blocked legislation to allow euthanasia or assisted suicide.

Last week the Bulgarian parliament Health Committee overwhelmingly rejected a bill to legalize euthanasia and the State of Oregon (where assisted suicide has been legal since 1997) passed a law making it illegal to sell, produce or distribute suicide Kits.

Today Lifesite News has reported on a vote in the lower house of Italy’s parliament to prohibit the starvation and dehydration of patients in a move that is seen as a response to the killing of Eluana Englaro in 2009.

In a 278-205 vote recorded in secret, the Italian Chamber of Deputies voted to approve the bill, which prohibits ‘all forms of euthanasia and all forms of assistance or aid for suicide.’

The law provides for the creation of Anticipated Declarations of Treatment (DAT), which are also known as ‘Living Wills.’ DATs will allow patients who are unconscious or otherwise unable to communicate to refuse treatments that are ‘disproportionate or experimental.’

However, under the bill the withholding of food and fluids is prohibited in all circumstances. It states that nutrition and hydration ‘cannot be the object of the DAT’ and ‘must be maintained until the end of life, with the exception of cases in which the same proves to be no more efficacious in providing the patient in the terminal phase with the nutritional factors necessary for the essential physiological functioning of the body.’

The measure now goes to the Senate, where it is also expected to be approved.

The bill originated in late 2008, while Eluana Englaro, a 38 year old woman in a ‘vegetative state’ but otherwise in perfect health, was being starved and dehydrated to death by decision of her father. It was introduced after the nation’s Supreme Court allowed the killing to proceed. Englaro died after four days without food or water after the nation’s president refused to sign the anti-euthanasia.

In Britain, since the Tony Bland judgement in 1993, the courts have allowed applications in Britain to remove nutrition and hydration from patients suffering from ‘permanent vegetative state' (PVS).

But the Italian move comes just days before an application to the Court of Protection in Britain to withdraw nutrition and hydration from a woman in a ‘minimally conscious state’.

The case poses a major threat to disabled people and if successful will take Britain several more steps down the slippery slope towards legalizing full-blown euthanasia - way beyond Italy.

More brief euthanasia updates from around the world – some good, some bad

I have recently posted two blogs giving a round up of international euthanasia news, both of which have attracted a lot of interest and have been copied onto several other websites.

Both are still steadily attracting new visitors and I get the impression that there is a lot of ignorance in this country about what is happening elsewhere.

The first of these gave details about moves in six countries to legalise assisted suicide or euthanasia all of which have been defeated in the last eighteen months.

The second listed twenty things Terry Pratchett’s documentary did not tell us about euthanasia in Europe.

Alex Schadenberg, who heads up the Euthanasia Prevention Coalition in Canada, has just sent out a newsletter with links to articles on his blog that may also be of interest to readers. Alex’s blog is a veritable feast of information about these issues.

There are first two good news stories. The Bulgarian parliament Health Committee has overwhelmingly rejected a bill to legalize euthanasia and the State of Oregon (where assisted suicide has been legal since 1997) has passed a law making it illegal to sell, produce or distribute Suicide Kits.

Then there is the bad news from two countries that have legalised euthanasia – both salutary warnings to us.

First is an article by Wesley Smith on Wesley Smith, ‘Where euthanasia meets organ harvesting’, on the new practice of retrieving organs from euthanasia patients in Belgium. I recently blogged on this myself and succeeded in getting the story into the Daily Telegraph and Daily Mail – but Wesley has fresh insights. He writes:

Some might ask, if these patients want euthanasia, why not get some good out of their deaths? After all, they are going to die anyway.

But coupling organ harvesting with mercy killing creates a strong emotional inducement to suicide, particularly for people who are culturally devalued and depressed and, indeed, who might worry that they are a burden on loved ones and society. People in such an anguished mental state could easily come to believe (or be persuaded) that asking for euthanasia and organ donation would give a meaning to their deaths that their lives could never have.

And it won’t stop there. Once society accepts euthanasia/organ harvesting, we will soon see agitation to pay seriously disabled or dying people for their organs, a policy that Kevorkian once advocated. Utilitarian boosters of such a course will argue that paying people will save society money on long-term care and allow disabled persons the satisfaction of benefiting society, while leaving a nice bundle for family, friends, or a charitable cause.

Finally a second article reports that the Netherlands is normalizing euthanasia of people with dementia, first reported here by the Daily Mail. The Mail uncovered the fact that a total of 21 patients with early-stage dementia, including Alzheimer’s, died by lethal injection in the Netherlands last year.

I was struck by the Swiss doctor at Dignitas suggesting to Terry Pratchett (who suffers from early dementia) in his controversial documentary last month that if he was going to end his life then he needed to get on and do it at a point when he was still mentally competent to make the decision. Chilling!

Pratchett had already said that if he ever lost the ability to dictate his novels he would not consider his life worth living, despite the fact that his wife obviously did and was keen to look after him. He claimed that he ‘knew better’.

It seems that some Dutch people are already doing what the Swiss doctor suggested. I suspect that the organs of people with early dementia would be healthy and fresh enough to interest transplant surgeons.

I wonder if that might be the next step for the Dutch.

World Elder Abuse Awareness Day (15 June) – A reminder to treasure, honour and protect the older members of our community

You are unlikely to read about it in the British press, but today, 15 June, is World Elder Abuse Awareness Day.

While most people today are aware of child abuse, it was not always so. Indeed, the concept was only developed in the 1960s. But that development has proven enormously important, as it has allowed us to focus our resources and energy on combating the problem.

Fifty years after child abuse first entered the public consciousness, another phenomenon is just coming to the attention of the public: elder abuse. Research suggests it is widespread and traumatic.

A recent report by the Care and Social Services Inspectorate for Wales shows a 9% rise in the number of adult protection referrals in 2009-10. Around 5,000 cases of abuse are being investigated in Wales every year, the majority of those cases involving older people.

On a regular basis we see media coverage about older people being mistreated. Elder abuse takes place in many different settings – for example, the older person’s home, care homes, nursing homes and hospitals. It happens when an older person’s human rights and dignity are violated. It can come through financial scams, physical attacks, sexual abuse, psychological abuse or neglect. The perpetrators are often in a position of trust and have control of the life of the older person.

Elder abuse can also include actions that many people might not consider. For example, physical abuse can include inappropriate use of medication or force feeding, emotional abuse can include treating an older adult like a baby or otherwise injuring his or her dignity, and sexual abuse includes any sexual contact with a person who is incapable of consenting.

Furthermore, older adults are particularly vulnerable to less common forms of abuse, such as neglect and abandonment, violations of rights to privacy, community support and information, and financial abuse, which is the most prevalent form of abuse among older adults.

Financial abuse is ‘the illegal or improper use of an incapacitated or vulnerable adult or his resources for another’s profit or advantage.’

This type of exploitation can take many forms such as forgery, misappropriation of cash or assets, abuse of joint accounts, or abuse of power of attorney. Signs of financial exploitation may include disparity between income and assets, unexplained or sudden inability to pay bills, inaccurate or no knowledge of finances, fear or anxiety when discussing finances, or unprecedented transfer of assets to others.

Financial exploitation of a vulnerable adult can occur:

1. Without the elder’s knowledge
2. By trickery, intimidation, or coercion, or
3. When the elder is too confused to give informed consent

A slight majority of financial exploitation victims are elderly females over age 70 who live alone. They may also suffer from one or more physical or mental impairments. Perpetrators are most often relatives of the victim, typically the adult children.

Nationwide financial exploitation is the third most frequent form of abuse after neglect and emotional abuse. Estimates are that 30-40% of elder abuse involves some form of financial exploitation.

It is often argued that legalising euthanasia or assisted suicide would be a recipe for elder abuse. Given the vulnerability of many older people, who already feel themselves to be a financial, emotional or care burden on others, this is a powerful reason for not changing the law.

There are too many people already who have an interest, financial or otherwise, in an older person’s death. Let’s not give them any encouragement. And let’s work to honour, protect and uphold the older members of our community.

The Bible insists that we respect and honour old people (Leviticus 19:32; Proverbs 20:29) carry their burdens; listen to their advice (Proverbs 23:22-23; Job 32:6-9) and serve them as we would serve the Lord himself.

I’ll leave the last words to Mark Cheesman, in a Triple Helix article on the subject:

The Scriptures do not hold older people up as infallible, and are honest about the besetting sins and faults of old age. But they also see them as given to the younger people for their profit, just as the younger ones are given to the older folks.

It is a stark fact that many non-Christian communities esteem their elderly people far more than does the Western church. We should main-stream the older people in our churches: honour and make space for their input, and seek their prayers and wisdom. We should make many fewer mistakes if we did! And old people would feel much better about themselves, and be spurred on to greater things rather than just feeling a waste of space.


Further reading

The International Network for the Prevention of Elder Abuse

Financial exploitation of the elderly

Vancouver Sun article

Action on Elder Abuse

Elder Abuse – Chipping the Old Block (Triple Helix)

Telegraph highlights my comments on End of Life Charter not addressing religious beliefs

On returning from a trip to Canada, for the Third International Symposium on preventing assisted suicide and euthanasia, I see that the Daily Telegraph has picked up on my earlier criticism that the End of Life Charter doesn't address religious beliefs'

In an article titled ‘Dying charter “doesn't address religious beliefs”’ the Telegraph reports:

Dr Peter Saunders, chief executive of the Christian Medical Fellowship, welcomed the introduction of the end-of-life patients' charter, drawn up by the Royal College of GPs and the Royal College of Nursing.

He said: "In the main it seems a good attempt to improve patient care at the end of life."

But he said it only made "passing reference to 'spiritual support'", while there was "nothing specific about understanding the patient's world view or religious faith and how it might help them cope with death."

He went on: "In particular there is no mention at all about understanding what beliefs the patient might have about life after death or how this might affect their dying process."

Dr Saunders, a former general surgeon, also thought there should be more emphasis in the seven-point charter - which is to be hung on GP surgery walls - recognising "the vulnerability of many people who are dying and a commitment to protect them from financial, emotional or physical abuse".

The Telegraph also reports that some of my thoughts were mirrored by Michelle Mitchell, charity director at Age UK.

Describing the charter as "a positive step", she went on: "But these aspirations need to be translated into action."

"Over 80 per cent of deaths in England and Wales are people over 65 years, yet they do not always receive the care they deserve at the end of life," she said.

"Older people must be able to expect more from their GP and wider healthcare team. All medical staff need more and better training on end of life issues, particularly communication, and there needs to be much closer coordination between health and social care."

New End of Life Patient Charter is a good start but does not go far enough

More than 8,000 GP surgeries in England will be asked to display a new patient charter on end of life care launched today.

The document contains seven ‘pledges’ to make the last few weeks and days of a person's life as comfortable as possible.

It also includes calls for healthcare teams to do all they can to preserve patients' ‘independence, dignity and sense of personal control’ along with ‘doing their utmost’ to ensure patients’ remaining days are comfortable, and that they get ‘all the specialist care and emotional and spiritual support (they) need’.

It has been created by the Royal College of General Practitioners (RCGP) and Royal College of Nursing (RCN) as an example of the ‘best practice’ all patients deserve from nurses and GPs in primary care.

Two of the seven points in the charter mention that patients’ intentions should be written down. The charter pledges that doctors and their practice teams will ‘assist you to record your decisions and do our best to ensure that your wishes are fulfilled, wherever possible, by all those who offer you care and support’ and advises that doctors and nurses should ‘ensure clear written communication of your needs and wishes to those who offer you care’.

We have heard an awful lot about dying in the last few weeks.

Two weeks ago we had national 'Dying Matters' awareness week, and this month is the International Society for Advance Care Planning and End of Life Care conference, being held in London. The NHS is also rolling out its National End of Life Care Programme, which works with health and social care providers across England to improve adult end of life care.

Of course charters, plans and awareness weeks are one thing and may well signify genuine good intentions. But the real proof of the pudding will be implementation at a time when health budgets are being cut and when elder abuse and poor care seems to be on the rise.

The charter comes hot on the heels of a report by the health services watchdog, the Care Quality Commission (CQC) which rated one in seven privately-operated care homes in Britain ‘poor’ or ‘adequate’.

Their inspections looked at nutrition and found cases of patients not being helped to eat, poor monitoring of patients' weight and people not being given enough to drink, with water being out of reach for long periods of time. In one case, a member of staff at Worcestershire Acute Hospitals NHS Trust said they had to prescribe water on medical charts to ensure patients got enough to drink.

So what should we make of this charter? In the main it seems a good attempt to improve patient care at the end of life.

Could it have been better? Most certainly! Here are three suggested improvements.

There seems to be a lot of emphasis on choice, independence, dignity and control. But I would have liked to have seen more recognition of the vulnerability of many people who are dying and a commitment to protect them from financial, emotional or physical abuse.

The charter makes passing reference to ‘spiritual support’ but there is nothing specifically about understanding the patient’s world view or religious faith and how it might help them cope with death. In particular there is no mention at all about understanding what beliefs the patient might have about life after death or how this might affect their dying process.

There is lot of emphasis about writing down patients’ wishes. One hopes this will not result in a push to make patients fill out ‘advance refusals’* that might conceivably be used against them later by someone with an interest in their death. I would recommend that establishing a lasting power of attorney (allowed for under the Mental Capacity Act 2005) is a better option: appointing someone you trust to honour your decisions. Better to rely on a trustworthy person than a piece of paper!

Is there anything sinister in this charter? I don’t think so. One does wonder how the emphasis on choice and control might work were assisted suicide or euthanasia ever to become legal. And no doubt the pro-euthanasia lobby will use this as another opportunity to advance their agenda. But given the huge opposition to legalizing assisted suicide or euthanasia from the medical profession I don’t think we need to have too much concern about that, at least in the immediate future.

In the meantime let’s see if this charter can be used to make a genuine positive difference in the way dying patients are cared for.

* There is lots of helpful background material on advance refusals in a previous statement on the CMF website.