Killing old people

First Published: 2007-01-19

Reprinted with the kind permission of The Spectator.

Many people with elderly or terminally ill relatives have had to confront the issue of whether it would be better if some way could be found to hasten their sick relative's death. Informal arrangements exist for hastening death within the Health Service. They often take the form of increasing the dosage of painkillers to the point where it will relieve the agony – and also ensure death. That's what happened in my mother's case. She had terminal and untreatable cancer. Her wishes were clear: she did not want to go on living in agonising pain. The doctors and nurses were equally clear about what was going to happen if her dose of painkillers was increased to the point where her pain ceased: she would die faster than she otherwise would. Her dose of morphine was increased. She died peacefully soon afterwards.

That seems to me to be the acceptable – indeed the right – way for doctors and nurses to hasten death. Unfortunately, it does not seem to be the only, or even the most common, way in which they actually do it. The experience of taking an elderly relative to hospital and finding that he or she is treated in a way which causes both pain and harm is frighteningly common.

Barbara Yeo is one example of that trend. She was an 83-year-old woman who was admitted to hospital in March this year for what was thought to be constipation. Within a week, Mrs Yeo was on the hospital's 'do not resuscitate' list. No terminal illness had been diagnosed. Her family found out by chance. 'I was having a conversation with one of the doctors,' Harriet Yeo, Barbara Yeo's daughter, explained to me, 'in which I wanted to ensure that all steps would be taken to resuscitate her if at any point she should lose consciousness. The doctor told me outright that he didn't agree with that. He didn't think she should be resuscitated. He added insouciantly that, nevertheless, he would "seek a second opinion on that topic".'

Since other doctors involved with her mother's care took the same attitude, that was not reassuring. 'One of them asked me, "How do you know she wants to live?" The real question was how he knew she wanted to die! I knew she wanted to live because she had said so dozens of times.' Harriet Yeo remembers that the doctor had insisted that he was 'qualified to judge quality of life'. The clear implication was that Harriet Yeo was not, and nor was her mother. The 'medical team' then exposed her to infection by bringing on to her ward another patient with a highly infectious bug. Mrs Yeo duly caught that bug. It killed her within a few days. And yet, Harriet Yeo insists, she had gone into that hospital as a woman of perfectly sound mind and reasonably functioning body; certainly she had nothing approaching any kind of terminal illness.

Harriet Yeo was so incensed by what happened to her mother that she has started Forgetmenot, a charity whose purpose is to try to ensure that the elderly are properly treated. She has been overwhelmed with people complaining that their elderly relatives had their pain prolonged and their illnesses worsened by medical neglect. Those cases include Charles Andrews, who was apparently left in terrible, unnecessary agony for two months because no one bothered to look at his test results; and John Williams, an 88-year-old who was admitted to hospital after being diagnosed as suffering from 'acute peritonitis'. Mr Williams was told he had three days to live and given no treatment. A second doctor gave him a final examination, and concluded he did not have peritonitis, just a gallstone, and his life was not in danger. But in hospital Mr Williams acquired an infection. The infection killed him. Mr Williams's death, like Mr Andrews's, will make an appearance in NHS statistics. The neglect responsible for it will not.

The failure to treat elderly people properly is sufficiently frequent to suggest that it results from a deliberate policy. When the BBC's Panorama persuaded a nurse in an acute ward to use a hidden camera earlier this year, all the instances of neglect she recorded happened to old people: elderly patients were left in excruciating pain because of a failure properly to administer their pain medication; their food was eaten by medical staff; nurses ignored their cries for help; and some elderly patients even died without anyone noticing what had happened.

Healthcare resources, as we all know, are not infinite: they have to be rationed somehow. The usual basis for making rationing decisions used by organisations such as the National Institute for Clinical Excellence (Nice), which decides what medicines the NHS should buy, is 'Quality Adjusted Life Years', or Qalys.

Treatments are ranked by their outcomes in terms of how many years of high-quality life they will give to their beneficiaries. Qalys do not favour old people: they do not have many years left, their score drops even lower when those years are adjusted for 'quality'. One effect of using Qalys may be that old people drop down the list of doctors' and nurses' priorities: they are, as I once heard one hard-pressed nurse say, 'all going to die soon anyway'. And if you are at the bottom of the list made by people who feel too busy even to look after those at the top of it, your chances of being properly cared for collapse.

The government denies this. Health ministers point to the fact that the NHS has a National Director for Older People's Services, Professor Ian Philp, whose brief is to 'stamp out ageism in the NHS'. They also insist that nearly half the NHS's total budget is spent on people over the age of 65. Which is true. The trouble is, two thirds of patients in hospital wards are over 65. Since hospital care is by far the most expensive part of the NHS, you would expect at least two thirds of it to go on the over-65 age group.

It doesn't. It may be that minimising treatment for the old is the most rational way to allocate the resources we have. The more brutal health economists argue that it just isn't worth expending too large a slice of scarce medical care on them; it means that those who have more to look forward to, who have not already had a chance to live a long life and who score high on Qalys, are denied it.

It is not a policy which ministers will admit to following. But perhaps they do – and perhaps they are right. But it surely cannot be right that old people should be so cruelly neglected in the way they frequently seem to be at present. To live for ever is not something anyone can reasonably demand. But the NHS certainly has the resources to ensure that everyone in Britain can die without pain and with a modicum of dignity. It is a monumental scandal that its resources are not being used to produce that result.

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The views expressed are those of the author, and not necessarily those of the Nassau Institute (which has no corporate view), or its Advisers or Directors.

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