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Provision of Hydration and Nutrition for the Terminally Ill

Oral Answers to Questions — Prime Minister – in the House of Commons at 11:30 am on 14th September 2011.

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Motion for leave to bring in a Bill (Standing Order No. 23)

Photo of Therese Coffey Therese Coffey Conservative, Suffolk Coastal 12:34 pm, 14th September 2011

I beg to move,

That leave be given to bring in a Bill to guarantee the right to provision of hydration and nutrition for terminally ill people;
and for connected purposes.

Water is the essence of life; we all know that without it we die. That is one reason why I support the charity Water Aid, for which I did a sponsored walk last Saturday.

Another topic that will come up for discussion in Parliament soon is the Hillsborough disaster. One of the tragic cases that arose from that disaster was that of Tony Bland. To remind hon. Members, Tony Bland ended up in a permanent vegetative state and was kept alive for some years. However, Airedale NHS Trust applied, in effect, to end his life by withdrawing ventilation, nutrition and hydration. The Official Solicitor appealed against that application and was concerned that it would amount to effective murder. The case law subsequently established by Sir Stephen Brown in that judgment classified the provision of nutrition and hydration as medical treatment. After nine days without receiving nutrition or hydration, Tony Bland died on 3 March 1993.

Further judgments have been made on those principles and guidance has reinforced them. Concern has been expressed that such decisions could be applied not only to people in a permanent vegetative state, but to those with a declining illness. That has led to many differing views in this House. I do not want to get into the detail of the Liverpool care pathway, and it is not the intention of this Bill to prevent or frustrate, but to open up the discussion on this matter. It is an important topic that Members should want to discuss.

This is a difficult topic to discuss. I hope that people do not face it in their lives, but when it comes to the death of an elderly parent or relative, we need to face it with a conscious mind. I expect that taking the decision to remove nutrition and hydration is not easy for doctors, and I am not trying to remove any kind of medical judgment. For the avoidance of doubt, the Bill is not a Trojan horse to bring in euthanasia or assisted suicide, or to start force-feeding people. However, we have to recognise that death comes to us all and we have to face the discussion about whether we should prolong therapy or withhold it. There are other discussions to be had about whether therapy is futile. I hope the House will agree that withholding water or food from somebody and, in effect, ending their life in a potentially painful and distressing way, sometimes without relatives even knowing that that decision has been made, is wrong. One aim of palliative care is to help people to die as peacefully and painlessly as possible.

I do not intend to speak for long on this Bill, but I hope that Members will recognise that this is an important discussion to have and that they would not wish any of their relatives or friends to die of starvation or thirst, and so will support the Bill today. I commend the Bill to the House.

Photo of Andrew George Andrew George Liberal Democrat, St Ives 12:38 pm, 14th September 2011

I pay tribute to my hon. Friend Dr Coffey for ensuring that this issue is raised in the House and that the debate on it is advanced. She approached the matter with characteristic thoughtfulness and great articulacy, as she has done on many occasions.

It was clear from the title of the Bill that this issue would bleed into the debate about the appropriate role of the Liverpool care pathway. Just as we debate many other issues, it is appropriate for this House to reflect on and debate the ethical questions that arise from this particular issue. As Benjamin Franklin said:

“In this world nothing can be said to be certain”—

Photo of John Bercow John Bercow Chair, Speaker's Committee for the Independent Parliamentary Standards Authority, Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Speaker of the House of Commons

Order. I apologise for interrupting the hon. Gentleman, but this is not a debate, as such; it is a consideration of a specific and narrowly drafted Bill. What I seek to ascertain at the outset is whether the hon. Gentleman is opposing the Bill.

Photo of Andrew George Andrew George Liberal Democrat, St Ives

I am grateful to you, Mr Speaker. Having heard what my hon. Friend the Member for Suffolk Coastal said, I have no intention of pressing the motion to a Division. However, the narrow title of the Bill relates to patients’ rights to hydration and nutrition, which raises the question of contradicting the General Medical Council’s advice—that is a medical decision rather than an issue of basic care.

Photo of Andrew George Andrew George Liberal Democrat, St Ives

Thank you, Mr Speaker.

As I was saying, Benjamin Franklin said:

“In this world nothing can be said to be certain, except death and taxes.”

As the House debates and comes to conclusions on taxes, it is also appropriate for us to consider—and to consider deeply—ethical questions such as the manner and process of death. We should ensure that end-of-life care and the ethical questions surrounding it are carefully considered.

It is my intention to deal not with the legal case surrounding the death of Tony Bland, but with the implications of the Bill on the GMC and on other guidance on the application of the Liverpool care pathway. Like others, I have been confronted by those issues, with the loss of a very close family member in recent months. Such questions inevitably and sadly confront us all.

Medical treatment of the terminally ill should be in the patient’s best interests. We should recognise that a blanket policy—of always providing, or of always not providing, artificial nutrition and hydration—would be ethically indefensible. Therefore, all decisions on medical interventions, which is what we are debating, should be based on sound, clinical judgment.

I agree with my hon. Friend that these matters should be kept under review. It is absolutely appropriate that the current guidance that applies is kept under review, and that the House of Commons and the House of Lords should be involved in debates on it.

The Liverpool care pathway is used in hospitals as a plan of care for patients in the last days and hours of their life. The pathway is recommended as best practice in the end-of-life care strategy. Patients should be involved in decision making wherever possible, and they have a right to refuse treatment in person, or in advance of a loss of capacity. Health care professionals should seek to provide the highest standards of care possible to dying patients. On occasion, that will involve recognising that a patient who is hours, or at most days, away from death, will be harmed rather than helped by the application of artificial nutrition and hydration.

The GMC guidance to doctors on end-of-life decision making states:

“All patients are entitled to food and drink of adequate quantity and quality and to the help they need to eat and drink…You must keep the nutrition and hydration status of your patients under review. You should be satisfied that nutrition and hydration are being provided in a way that meets your patients’ needs, and that if necessary patients are being given adequate help to enable them to eat and drink”,

hence the application of the artificial intervention to assist them.

The guidance also states:

“If a patient is expected to die within hours or days, and you consider that the burdens…of providing clinically assisted nutrition or hydration outweigh the benefits they are likely to bring, it will not usually be appropriate to start or continue treatment.”

Similar advice is provided by the National Council for Palliative Care.

The benefits of artificially provided nutrition and hydration include the potential to prolong life and improve general well-being. Artificial nutrition could prolong life in patients with obstructing tumours, such as throat cancers, or those with diseases that prevent them from swallowing, such as motor neurone disease. Artificial hydration could in certain circumstances also relieve thirst.

However, there are also risks. In some circumstances, artificial nutrition and hydration will only prolong the period of suffering, and there could be complications associated with having tubes inserted. Fluids given via drip can exacerbate oedema—swelling—and increase leakage into body spaces that can lead to a more distressing death, for example if fluids get into the lungs.

It is important, therefore, that in debating this issue, as I hope that the House will have time to do—because it needs to be kept under review—we will have an opportunity to consider the risks of continuing to apply artificial nutrition and hydration. That issue has been well covered by the General Medical Council and others in the clinical guidance that needs to apply here. The Liverpool care pathway has been accused of encouraging a tick-box culture that does not consider the whole patient and their needs. We have to ensure that the highest-possible clinical standards are applied when the LCP is administered. Equally, as my hon. Friend said, we have to strike a balance between the patient’s best interests and wishes and the wishes of the family close to the terminally ill patient. She emphasises, in the title of the Bill, that this is a matter of the right to treatment, but it is also a matter to be balanced with the right to ensure that medical interventions are in the best interests of patients. On that basis, I wish to ensure that we strike a balance when we debate the Bill.

Question put and agreed to.

Ordered,

That Dr Thérèse Coffey, Andrea Leadsom, Penny Mordaunt, Harriett Baldwin, Jim Dobbin, Thomas Docherty, Mr Andrew Turner and Dr Julian Lewis present the Bill.

Dr Thérèse Coffey accordingly presented the Bill.

Bill read the First time; to be read a Second time on Friday 25 November, and to be printed (Bill 230).

Photo of Thomas Docherty Thomas Docherty Labour, Dunfermline and West Fife

On a point of order, Mr Speaker. This is a genuine question. Will you clarify for Members the rules around speeches during the presentation of a ten-minute rule Bill?

Photo of John Bercow John Bercow Chair, Speaker's Committee for the Independent Parliamentary Standards Authority, Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Speaker of the House of Commons

I am happy to advise the hon. Gentleman and the House. A Member introducing a ten-minute rule Bill has up to 10 minutes in which to do so. A Member who wishes to oppose the Bill similarly has up to 10 minutes in which to do so. Those 10-minute allocations are distinct and separate from each other. It is helpful if a Member who is opposing a ten-minute rule Bill makes it clear that that is what he or she is doing. There is, to be fair, no obligation to test the will of the House by submitting the matter to a vote, but it is important for the orderly and intelligible conduct of business that an opposing speaker makes it clear, preferably at the outset, for the benefit of the House, that the speech is one of opposition. I hope that the hon. Gentleman’s brow is no longer furrowed, that he is duly reassured and that the House as a whole is appropriately enlightened.