What services could be expected in the UK?
“If you get it done in Switzerland, it will cost you more than £10,000. So, if you can’t afford that, what are your alternatives here in Britain ?”
A criminal offence
It is a criminal offence in the UK to help anyone to end their own lives. If you are a patient of any kind, you will run a serious risk of being classified as a “suicide risk” if you even ask about it. If you conduct a brief search for end-of-life opportunities you will find impressively thorough information about
- Care at home
- Hospice care
- Hospital care
- Residential care homes and nursing homes.
but if you so much as mention that a trip to Switzerland might also be in your mind, everyone will tell you to dismiss such thoughts immediately.
They have got to. To do otherwise could involve their own implication in what might turn out to be a criminal activity – the law calls this “an act capable of encouraging or assisting the suicide or attempted suicide of another person”.
“Making her comfortable”
Having said that, there are certain conversations that can be had in a sort of coded way where both sides understand what is really being talked about but no one dare be too specific about it. Patients can be “made comfortable” and “we’ll make sure she isn’t suffering too much”. It is widely recognised that doctors can increase painkilling dosages to levels where the risk to life is greater from the painkillers than from the illness itself. Phrases like “syringe driver” enter the discussion. The ultimate form of palliative care for severely suffering and terminally ill patients may be “continuous deep sedation”.
There is no doubt that such painkilling methods as are now available have made the process of death much more tolerable than it was a hundred years ago. However, the degree of pain remaining is frequently very great. Also, what really frightens many patients as much as the pain is the prospect of incontinence, constipation, incoherent rambling or terrible skin conditions that effectively remove all their former efforts to be a dignified and presentable human being.
A number of patients choose to starve themselves to death and it is perfectly legal for hospital staff to allow them to do so. Yet that, too, remains a very unpleasant experience. Death usually occurs within ten to fourteen days; it is the absence of fluid, rather than the absence of food, that causes the heart to stop. This method of suicide is called “VSED” which stands for “voluntarily stopping food and drink”. There are several VSED websites, predominantly in the USA.
Fears about all these processes are totally logical and totally real. Anyone seriously considering the four options listed above may well want to add a fifth; determine the last day yourself and get it done in Switzerland.
Paying for your care
Of the four options to be discussed as above (i.e. excluding Switzerland), the State can be expected to pay for three of them – well, three-and-a-half. Since 1945 the general basis of agreement in Britain is that you can expect the State to pay for your medical needs but not for your “care”. In other words, UK citizens can expect to receive NHS treatment without cost; more accurately described as “free at the point of delivery”. This cost-free arrangement is also the basis for hospice care, whether received at home or in a hospice itself. In 1945 any cost of “care” was expected to fall on the individual or their family. “Care” really just means the cost of getting old. Being elderly and frail was not regarded as a specific illness. So if you had to go into a residential care home you were expected to do so at your own expense.
Since 1945, the increase in the number of over-eighties in our population has caused the Government to accept greater responsibility for the wellbeing of the elderly. This is normally provided through the Adult Social Care Departments of Local Authorities. In principle, “care” is still the responsibility of individuals and their families but, under new legislation, there will now be a ceiling of £86,000 upon the amount that any individual is expected to pay during their lifetime. Once you have spent more than that, the State will pick up the bill. This change was due to come into effect in October 2023 but, as part of the Autumn Budget statement in 2022, the date has now been changed to October 2025.
The average weekly cost of a residential care home in England and Wales is now £860. It is at its highest in Islington (£1,500) and at its lowest in South Wales (£680). Under the new legislation, if you have less than £20,000 in assets then you will not have to pay anything. With more than £100,000 you will have to pay the lot, subject to the £86,000 lifetime mentioned above.
With assets, including the value of your house, between £20,000 and £100,000 the costs of your care, whether received where you live or in a care home, will be split between you and the State. Inevitably the calculations for this split are very complex and will be calculated for you by your Local Authority.
The work done by Hospices is regarded as “treatment”. So there is no charge to patients. However, nearly all Hospices are charities and typically raise about 65% of their own costs. The other 35% comes from the Government. The private money raised by Hospices comes from their high street charity shops and from legacies.
Now, the blunt truth is that if you find yourself having to choose between a Hospice and one of the Swiss end-of-life centres, you have almost certainly left it too late.
A Hospice is a place used by someone who is dying. Many Hospice services are not provided in the Hospice’s own building but are instead given to patients in their own homes – frequently assisted by Marie Curie nurses, Macmillan nurses, NHS nurses and Local Authority social workers. Once you are on a “pathway for the dying” (seriously) a whole apparatus of care and treatment systems seems to kick in and the help you get is enormous.
However, the average length of stay for someone who is literally “in a Hospice” is only two weeks. That is sometimes because their stay was only ever intended to be temporary – usually a respite break for caring relatives. Or else, it can be the result of inevitable death. Of course, several patients last longer than two weeks, occasionally even months. But once you are in a Hospice, you will probably not have the time or the physical ability, even with the help of a well-meaning relative, to make arrangements to visit Switzerland.
Therefore, if you want that fifth option to remain open, make sure that you plan accordingly several months, if not years, beforehand.
The medical profession continues to have ambivalent views about suicidal thoughts themselves. They are usually regarded as a symptom of other problems, most notably severe depression but, increasingly frequently, they are seen as a problem in their own right. Individual medical practitioners can actually be very sympathetic when the reasons for ending your own life are quite logical. Collectively, however, the prevailing view is that something is seriously wrong and that the patient must be “helped” in some way. In prison, inmates can be put on “suicide watch” and all means of ending their lives are removed. Within the Beck’s Depression Inventory, question nine specifically asks about suicide and you score a 3 (the highest) if you say “I would kill myself if I had the chance”. Tick that box and alarm bells will ring.
One particular case is illuminating and rather frightening. Michael (not his real name) was 61 and became worried that he might be suffering from early-onset dementia. His doctor referred him to a specialist consultant who confirmed that he was – specifically, from Alzheimer’s. The illness was at a very early stage, which meant that Michael would still be judged able to make a reasoned decision about assisted suicide. When Michael told the consultant that he had long been a member of one of the Swiss assisted-dying centres, the consultant replied immediately that he would therefore give Michael a “dual diagnosis” and that Clinical Depression would be added, “because you have been having dark thoughts about suicide” said the consultant. Knowing a bit about medical practice, Michael realised that if he was given any medication for the “Clinical Depression” he would no longer be able to satisfy external doctors that he was still competent to decide upon his own self-administered suicide. Michael was, however, able to persuade the consultant not to prescribe medication but to prescribe a course of counselling instead. Otherwise, the Swiss option might have been closed.
Finally, painkilling medication is no longer available as easily as it was. One GP recorded a home visit to a terminally ill patient as follows :
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“My last patient of the day lived with her adult relatives. Terminally ill and recently discharged from hospital, she needed pain relief, something to ease her passage from life to death. I looked helplessly at her family. What could I do? My doctor’s bag contained nothing that could ameliorate her suffering. When I started out as a GP, my bag contained ampules of morphine and other painkillers, but those days are long gone, since the restrictions imposed after the murderous actions of Harold Shipman. That evening, I was all there was. My only option was to suggest a transfer back to hospital. I, but more importantly the system, had failed her in her final hours of need.”