Thinking About (Assisted) Dying

When I was really very young – no more than five or six years old – my Grandma, then a sprightly little silver-haired woman in her late sixties, made me make her a promise: That if, when she got older, she ‘went ga-ga‘ or ‘lost her marbles’, I would ‘bump her off’, and ‘put her out of her misery’. It was a promise she reminded me of periodically over the following years. Her greatest fear was losing her identity, her capacity – her very self – to dementia, as she had seen happen to others.

Not much more than a decade after this, she died, confused and disorientated, having been unable to recognise me, her own children, or her other grandchildren, for the previous couple of years. Her worst-case scenario made real. Obviously, there was nothing I could have done to fulfil my promise. For all that it wasn’t exactly made freely, or from a place of informed consent, the fact that neither I, nor anyone else, could help spare my Grandma from her worst fear at the end of her life has haunted me.

In the UK, we’re talking about assisted dying again, as legislation that would allow terminally ill people to choose to die by self-administering medication under clinical supervision is about to be brought before Parliament. It’s not the first legislation of its sort that has been brought, and previous efforts to decriminalise medically assisted suicide in the UK have failed to pass. The mood music seems different now; who knows, it may be the time.

Eight years ago, more or less a decade into my career in veterinary practice, my Dad died from an aggressive form of T-cell Lymphoma. I was with him, at home, when he passed away. (The incredible haste with which he was discharged from hospital with little more than a community DNR form in his hand, and the lack of appropriate support for this, when he expressed a preference to die at home rather than on a ward, is beyond the scope of this piece really: but suffice to say I have never seen the NHS move faster to do anything, ever). In his final few days, he was in a terrible state, unable to eat or drink, distressed and upset and confused and undoubtedly in pain (not to mention horrifyingly thirsty).

If I allowed one of my veterinary patients to die like that, I would be struck off (and rightly so).

His final few hours, thankfully, were calmer, greatly eased by the care of a wonderful Macmillan nurse (and the great big carrier bag of end of life medication prescribed for this occasion by his GP).

This has always seemed to me a straightforward matter of personal choice – of basic bodily autonomy, in fact. I should not – no one should – be required to continue to live if life is unbearable (that notion is outrageous!). In the event I am unable to take the necessary steps to end it quickly and efficiently by my own actions, help should be available (as it should be if I were unable to perform any other basic and necessary task).

But.

I have listened to disabled and chronically ill friends (and joined their community myself in the past couple of years). I have paid attention to how these systems work in countries that have already implemented assisted euthanasia programmes. I am well aware of the absolutely abysmal state of social care and palliative care in this country. And despite the fact that I still, viscerally, feel that this is a choice *I* would want for myself, I’m genuinely ambivalent about whether I believe a system can be created that doesn’t – by intent or omission – create perverse incentives. In our existing situation in the UK where good quality, humane end of life care is a luxury available only to the very wealthy (and to a lucky but tiny minority who are able to access hospice care), I think the creation of such incentives is almost inevitable.

This has been widely discussed already, and I have little new to add here beyond an abiding feeling of discomfort.

I do, however, have a personal perspective to bring to bear, and it’s one that I’ve rarely heard in this conversation. A medical doctor, in a TV Vox Pop, said “I trained to be a doctor to save life, not take it.” As veterinary surgeons, euthanasia is an essential part of our toolkit. I have brought many lives to an end. You may not think animal lives are remotely equivalent to human ones – but if you have loved pets of your own you will know how profound and important those relationships can be. For many people (including me) pets are family – for some, their only family. The death of a beloved pet can be just as important and traumatic a bereavement as the loss of a close human family member.

Just like doctors, I am caring not just for the dying patient but also for their human family. The emotional intensity and complexity around deciding to end the life of a dearly loved pet is one that many of us have experienced for ourselves. As a veterinary surgeon, I am not merely there as euthanasia technician but as clinical advisor, advocate for the patient’s welfare, and frequently as mediator between the differing opinions of the humans who love them.

I have some now well-rehearsed answers that I trot out when one of my more empathetic clients says, often through their tears, “Gosh, this must be hard for you, too.”

“Well,” I say, “obviously it’s no one’s favourite part of the job. But I’m not emotionally attached to them the way you are, so it’s easier to see things clearly, to know that it’s the right thing to do, with a bit of distance.”
“It’s a blessing, really,” I say, “it’s an incredible privilege to be able to spare our patients from distress and suffering, to release them from pain and let them pass away peacefully.”
“I don’t know how human doctors do it,” I might add, depending on the client, “it must be awful not being able to spare their patients, in the end.”

And they nod, reassured, I hope, and I tell them again how sorry I am for their loss, that it was the right time, and that this moment, today, awful as it is, isn’t what they’ll remember, in the end. That stronger and happier loving memories will stay with them.

I don’t tell them that every single one of these moments extracts a cost. That having a front-row seat – a starring role – at one of the worst moments in peoples’ lives, helping to manage their distress while also managing the practical aspects of administering IV medication to patients who are often confused, distressed, dehydrated, in poor cardiovascular status, is not merely technically challenging but requires a degree of compartmentalisation and self-management which is both difficult and, cumulatively, undoubtedly pretty unhealthy. Ask any veterinary surgeon you know well enough, and they will tell you some of their nightmare stories of euthanasias gone wrong – the memorable, horrifying, and often dangerous events when things don’t go to plan. But for me at least, even the calmest, most straightforward, most necessary and appropriate (not too early, not too late) euthanasia comes with a measurable personal price.

I am steadfast in my belief that euthanasia in veterinary practice is an essential part of the toolkit, one of the most powerful things I can do as a practitioner to relieve suffering and distress.

But.

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[The header image is a modified version of ‘Houses of Parliament and Elizabeth Tower’ by Flickr user ‘trecca’. The original image is licensed under the Creative Commons CC:by-sa licence, and the same license applies to the edited image above. The original file can be found here.]