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Withdrawing Treatment

Duration:
45 minutes
First broadcast:
Thursday 28 July 2011

Palliative Care teams are used to supporting patients at the end of life. But recent requests by two patients with motor neurone disease make some medical staff feel uncomfortable.

They both want to stop using the ventilator mask that is keeping them alive.

Initially prescribed to support breathing at night, their symptoms have progressed to such a degree that they can nolonger breathe without the mask.

They are aware that removing it will lead to death within hours or minutes. They both ask the palliative care team to ease their suffering during the process.

Patients have a legal right to refuse treatment, but these requests make some staff uncomfortable. Can they conscientiously object to supporting these patients at the end of their lives? Could they be accused of assisting in their deaths?

Producer Beth Eastwood

Presenter Joan Bakewell.

  • THE PANEL

    Rob George, Professor of Palliative Medicine at Kings College London and Guys and St Thomas’ Hospitals. He’s a member of the Ethics Committee at the Association of Palliative Medicine

    Dr Fiona Randall, Consultant in Palliative Medicine, at the Earl Mount Batten Hospice, Isle of White. She’s written extensively on the philosophy and ethics of Palliative Care

    Deborah Bowman, Senior Lecturer in Ethics and Law at St George’s University of London

  • EMAILS FROM LISTENERS

    I’d like to thank you for putting on this programme. I have found it fascinating, beautifully and sensitively put together, a very intelligent and thoughtful consideration of extremely difficult subjects.

    As a Christian, I have found it very moving to hear how everyone involved considers these issues so seriously and carefully, and tries to act in the best way possible for all those involved.

    It gives a very positive view of the health service, to counter some of the very unhappy headline cases we hear of more commonly.

    It is a shame that often people feel they have to take sides in these dilemmas, when in fact human situations require humane and loving responses.

    Joanna Waller, F.I.T.I., C.L. (T)

    ---

    My brother and I (in our 70s) had a long-standing, empathic, reciprocal agreement, regarding the end of life. When he had a stroke (on top of being an Asperger) the medical 'profession', when not letting him down badly, obstructed me and pressured him (extracting signatures) such that he died, by inches, over 8 months he did not want.

    We (western humans) are deeply immature regarding death. I plan to outwit the 'life at any cost' brigade.

    Barrie Singleton

    ---

    I have just listened to your programme which brought back sad memories though no regrets. My husband was diagnosed with MND in Feb 2006. He had the form that left him completely paralysed within months of diagnosis. He was on a ventilator from August 2006 at night and from November was using it 24 hours. We were given excellent advice by our consultant Mr Allan at Stoke Hospital. We were also lucky to have had excellent palliative care delivered at home. Our problem came when Steve decided that enough was enough when his swallowing became severely affected and he wanted to die at home. After much legal wrangling we got our wish and with support from the doctor at our nearest hospice, our palliative care nurses and Mr Allan, Steve died peacefully in my arms after I had removed his mask. It took only minutes but all his family were there and he had his wish to die at home. He died 4 days before his 47th birthday and 23 months from diagnosis. It took me 5 days to get a death certificate which was eventually signed by the hospice doctor who had visited him.

    I have lived with this for over 4 years. I spoke at the West Midlands MND conference but have never heard of other cases. It’s good to know that you are not alone and that others have been faced with the same decision and chosen the same route. I wish both wives well and hope that they are able to rebuild their lives as I have.

    Clare Mills

    ---

    Thank you for today's programme. I nearly switched off as it is a subject rather 'lose to the bone' for me. With MS I often muse about in what manner my days will end - the withdrawal of feeding/water & a painful slow one? I felt comforted that this could/would be mitigated with the aid of drugs to 'relax' me.

    I also feel able to talk to my heath care professionals about my likely/possible death - hopefully still some years away, but as someone who could not bear riding at the back of a tandem, I would like some control over & choices about my death if possible!

    I was left with a strong feeling that doctors' training in future should have a significant emphasis on end of life practises - more & more of us will live longer & longer as we are progressively patched up into our ninth & tenth decades.

    Surely for a doctor a caring exit is as important as one while living?

    Caroline Howlett

    ---

    The objections of medical staff concerning the withdrawal of breathing masks are totally illogical. The problem seems to be that death will quickly follow. Yet medical staff frequently observe people taking weeks to die after the withdrawal of food and water. Which is the more ethical option?

    Linda Warr

    ---

    What a relief to hear informed and educated people so thoroughly unravelling the many aspects of the ethics involved in today’s subject. But why oh why is it only now being attended to?

    Certainly 20 years ago during normal, everyday nursing I remember talking with a colleague about the request of an old lady not to have CPR attempted on her should she die. Three times that request was ignored and she died with broken ribs and covered in bruises, a gross act of assault. I am aware of course that this is “different” to the cases discussed today. But the point was that my colleague seemingly refused to consider the fact that assault was committed and that had legal implications. His words were “I don’t care, I am going to watch my back”. The frustration of dealing with such ignorant and bigoted views is immense. Certainly in my view, those nurses who ‘refused to be debriefed’ after Dennis’s death in hospital should be suspended until they agree as their refusal to be educated and shown the illogicality of their views constitutes a danger to the people unfortunate enough to be in their “care”.

    Education is, of course, the answer. And if, as a modern society, we could all be brought back to the basic fact that we all die, death is a fact of life, and the more it is discussed the more chance everyone has of “having a good death” then an enormous amount of anxiety could be allayed. I also remember going to a hospice back in the 80s as part of a course as I was very concerned with pain control. I was flatly told that there was no way in extreme cases it could be controlled because of the perceived threat of accusations of euthanasia.

    Another aspect of today’s discussion: it was stated that the perceived quality of life of the person himself was the only criteria by which the action to remove the masks was ultimately taken. That also, of course, applies to all cases rather loosely termed ‘euthanasia’ when a person of sound mind has decided that his/her quality of life no longer meets the desired level.

    Lots and lots more open discussion please. Use the telly for goodness sake, at a time when at least teenagers might be watching and grow up with the ideas implanted so that they may have open and frank discussions amongst their peers at a time when opinions are formed. Sounds a bit manipulative /doctrinaire but there is a big difference and the idea is not to brainwash as in Rwanda, just get objective discussion going.

    Thanks again for a ‘good’ programme

    Patricia Spencer-Barclay, EN(G), RGN, OND, BSc

    ---

    This programme made me weep.
    Please give the two ladies concerned my admiration for their kindness and tell them how jealous I was listening to the programme that I couldn't do something similar for my late wife, also let the medical teams know how much we appreciate their consideration and care in this sort of situation.

    Yours sincerely - Ken Leckenby

    ---

    I listened with keen interest to the programme today as my husband died from MND 6 years ago.

    In the cases discussed today, I felt that the response of the various family members and medical teams was made more traumatic as the patients had discussed their wishes with them.

    My husband had been taken into the local hospice for respite treatment. Perhaps they knew that he would not live for much longer.

    We were told to expect him to go home within a few days having been stabilised. I later wondered if it had all been staged by him as he asked for family and close friends to visit him. His elderly parents were staying with us and arrived at his bedside during the morning as scheduled. He then wrote that I should take them to lunch at the local pub. A ritual for them at 12 o'clock. Resentfully I took them and later returned to find he was experiencing difficulty in breathing. In fact he was pulling the mask off and nurses struggled to replace it. He died shortly afterwards, with nurses and myself at his side.

    In an unselfish way I now feel, he had pre-empted any moral or ethical dilemma for us as he had taken the decision himself to remove the mask. The sadness for us was the shock that he would not be coming home and that we were not present but doing trivial things. Perhaps that is better, to carry on with our normal lives as "we do not know the time or the hour of our calling"? We still miss him very much but know he would have hated to be unable to communicate at all and was at that stage of having great difficulty typing and almost unable to move any limbs, let alone speak.

    Your broadcast has helped me to galvanise my thoughts, thank you

    Marianne Buckley

    ---

    Thank you for raising the patient’s right to an opinion as to when they die if they have a terminal illness. I thought the days were past when doctors, nurses and others in the medical profession thought they were God and imposed their will on the terminally ill albeit in what they thought was the patient’s best interests. It was interesting to hear the patient’s and their loved one’s points of view expressed.

    However, in the case of Alzheimer’s the end is not so clear cut. My husband has Alzheimer’s and signed The Living Will many years ago as I did, witnessed by my doctor. She said she would respect our wishes but she couldn’t guarantee that others would. I believe The Living Will is now Legal and has to be respected? However, that doesn’t solve all problems for us. If my husband develops another illness and needs medication, yes you can refuse treatment BUT in the case of Alzheimer’s, Parkinson’s etc they end up having all their bodily needs performed by others and in the case of Alzheimer’s unable to talk or think. What quality of life is that? Why should someone else’s religious or ethical views force him and his close family to go through a living hell? We all have the moral obligation to decide for ourselves and the sooner the government finds out that that is what the majority of the population wants and change the law the better for everyone.

    Wilna Roberts

    ---


    This is a superb series and today's - 28 July - was outstanding in its exploration of a critical ethical area. I hope it adds to the debate around end of life choices. Joan Bakewell is absolutely perfect in questioning and presentation.

    I hope it may be possible to tell the two wives involved in today's programme how much they are to be admired for their love, honesty and courage.

    Judy Jacques

    ---

    My late wife, then aged 42, was diagnosed in 1981 with a leiomyosarcoma, situated adjacent to the R kidney, but not involving the latter or any other organ. The tumour was removed by laparotomy followed by radiotherapy; there were further metastases (polyp on the colon; tumours affecting the uterus, ovaries and omentum; another abdominal tumour) culminating in an inoperable tumour in the pelvic floor diagnosed in late 1984. Symptom control was initiated with continuous diamorphine (low dose, 30 mg/4 hr by syringe driver), which by May 1985 (when her condition was considered terminal) by degrees had been increased to 7.2g/24h. The effect of such a massive dose was to immobilise the bowel and prevent the passage of faeces, which before that increase would have been accompanied by excruciating pain. In discussion with her doctors my wife asked for sedation; this was achieved with, I believe, heminevrin delivered by a drip. When I saw her first after this procedure was initiated she was in a coma and apparently pain-free (to my considerable relief). She died 36 hours later, still unconscious.

    During the terminal stage of her disease my wife had several times made it clear that she wanted to die in order to be free of intolerable and uncontrolled pain and wanted the doctors to treat her in such a way that this could be achieved. I believe that her wishes were fulfilled satisfactorily and legally.

    Michael Tremberth

    ---

    I want to say how much I got out of today's broadcast.

    Firstly, it tackled the issues unsentimentally and without the oddly-impassioned views of people who have no interest whatsoever in the family concerned, and want only to promote their own beliefs. This was a huge relief.

    Just as importantly, though, the participants gave a very fine analysis of exactly what is going on when someone makes the decision to stop treatment and hence to die. As was pointed out, the public (including myself) finds itself very confused about events during a death that results from human intervention. Even the GP and nursing staff - who live with matters of life and death - found themselves confused and uneasy.

    The programme clarified many issues very helpfully, for example the difference between acting to end someone's life when otherwise they would live (e.g. lethal injection) and allowing them to die as a consequence of their disease. The former is - in law - murder, while to prevent the latter, i.e. to artificially prolong someone's life against their will, is a type of assault.

    Thank you all very much.

    Alison Campbell

    ---

    Thank you for giving air time to this subject. I only caught the end of your program this morning driving between appointments, however the issue of managing the end of life is something about which I feel, with a passion, needs much wider debate. It was good to hear your discussion which one can only hope will encourage others to feel brave enough to speak up or out about - whichever camp they are in.

    I have watched my sister die of cancer in her early thirties then my mother die of Alzheimer's Disease in her sixties. In both cases this was not pretty or dignified, nor free from pain or mental anguish. The latter stages of suffering with Alzheimer's are especially imprinted on my memory. At times it was just hell - as it was for those left to wait and watch.

    We have (as a race) become too good at artificially extending human life far beyond the point that nature ever intended. You and I would be locked up for putting a pet through the torment and torture suffered by some folks simply because they can be kept alive - with no discussion as to whether it is appropriate or acceptable to do so.

    My father now has Alzheimer's. When diagnosed his wish was "to knock myself on the head before I get like your mother". So I removed his guns, took away his knives and moved him away from his long time home to somewhere safer. So he remains a progressively more tormented soul, who in lucid moments knows only too well what awaits him - and doesn't want to go there. And I will remain wracked with guilt, continue to mop up the mess as it worsens over time and can only watch his suffering worsen. What a merry carry on.

    Is this really the way to go? Is this civilised or barbarous? With more and more of us likely to live longer and therefore more likely to suffer from this and similar disease is subjecting so many to such suffering right? As I say it was good to hear you giving air time to this, hopefully the debate will grow

    David

    ---

    Thanks you so much for your excellent programme this morning.

    The final comments were most pertinent to us all. Once medical staff, of all types is made aware that administration of treatment against the wishes of the patient or their carers is a form of assault we will have a more rational approach to end of life issues.

    Sadly I was not surprised but still horrified by the treatment of the families by the GP and ward staff. They had NO right to express their personal opinions. If they had issues these should have been kept between them and their supervisors or medical bodies. The extra stress this unprofessional, selfishness must have caused was intolerable.

    I worked for 15 years supporting families where a member suffered from dementia and saw this attitude constantly; from GP and home nurses, nursing home staff and hospital staff. People were being treated as a knee jerk reaction by staff where it was long past being appropriate. It was heartbreaking. I even saw a doctor who ignored a DNR on her notes, even when it was pointed out to him and resuscitated a 92 year old lady. She died a few weeks later. One of the worst incidents was by a matron of a nursing home who took it upon herself to put up a drip on a lady with advanced dementia against the wishes of her husband and the instructions of the GP. I can still remember the husband's distress as he called me for advice. These were loving families who did not want their relative to suffer any longer and were aware that could the person express themselves they would have refused treatment. Sadly we have no cases where someone in the medical profession has been sued for TREATING someone. When/if that happens it will concentrate minds. I have an Advance Directive which charges my children with doing just that if anyone ignores my wishes.

    Hundreds of millions of pounds would be saved each year if as a nation we could accept that dying is a natural result of illness and treatment should only be given if it is truly in the best interests of the patient or to relieve their suffering. Better still it would save the suffering of thousands of elderly people in particular and the distress to their relatives.

    There is a huge education programme needed before entrenched attitudes are changed particularly in people with strong religious beliefs of their own. These have no place in the treatment of others. Each time we interfere with the natural process of illness and TREAT someone we are acting like God, not when we withhold treatment.

    Penny Weaver

    ---

    I just wanted to thank you for one of the most compelling, intelligent radio programmes I have heard in years.

    Mark

    ---

    I have for the last 25 years been an Operating Department Practitioner - ODP - (previously known as Operating Department Assistant - ODA) so have a lot of experience of treating ventilated patients at the end of their lives as well as saving lives.

    I can appreciate that some healthcare personnel may feel uncomfortable at withdrawing treatment but essentially that is the right of just about any patient who is deemed well enough to make decisions about their own care. Yes, removing the mask will lead to death in a matter of minutes or hours but it is only the time-scale we are altering; the patient will inevitably die from their condition despite any and all of our best interventions. In essence I see this as no different to a cancer patient who refuses to undergo radiotherapy and/or chemotherapy in the full knowledge that without it they will die. It is their right to choose and our duty as healthcare professionals to provide them with the best level of care that they desire to have; no more, no less.

    The multi-disciplinary team should all have the opportunity to have discourse but ultimately we must serve the most important person - the patient. I am minded of an adage of Florence Nightingale; "At least do the patient no harm". Healthcare is slowly approaching the concept of holistic care; we must consider not only the physical but also the emotional wellbeing of the patient. Why should they endure the torture of a treatment with which they are uncomfortable, especially as they approach death - here the priorities to the patient should be dignity, comfort (with analgesia if necessary) and empathetic respect.

    John Richards MA BSc DipEd

    ---

    This programme covered a complex topic with admirable clarity. May we look forward to more on the whole subject of managing one's own death, including the taboo on suicide in near-death situations? The deficiencies of the present legal and professional ethical framework were highlighted by the prolonged death of one of the men in focus, which surely would have caused him distress if he had seen what his loved ones were going through to let nature take its course rather than accelerating the process.

    It would greatly improve the quality of life of the elderly if they could be relieved of the fear of interference with their wishes for the sake of the consciences and careers of those in the palliative industry.

    Arthur Rothwell

    ---

    Listening to daytime R4 on my day off, I thought I would make a comment about dying, 'the last taboo' at the NHS...

    Personally I should like to see detailed questions about brain injuries, terminal illness and dying as part of the regular routine when registering with a GP or on admission to hospital, whichever occurs first.

    Software to make 'What if...?' a simple choice that can be ticked, and secured, including not just withdrawal of treatment in certain situations, DNR etc, but also an option for organ donation, could easily be incorporated in current systems to help manage these 'final questions' to everyone's satisfaction.

    Thank you for your interest, and for raising this

    Joy

    ---

    I have been listening to The Ethics Committee since its start during which time the issues for debate have become more complex. It has made me think more about how decisions are made and what factors have to be taken into account. I admire the patients and families who have been willing to talk about the facts and their feelings.

    The last programme with the two men who had MND was more straightforward to me as I too took a decision not to have life prolonging treatment when I did not think that there was any quality of life to be gained. In my case it did not result in a quick death but I still think I made the right decision. However, for some of your listeners I can see that the idea of not prolonging life is not the same as opting for suicide might be something to chew over.

    Please continue to extend our understanding of the issues involved and
    to challenge our preconceptions.

    Margaret Tuck

    ---

    I listened to last weeks' programme about MND - and feel that the reason the wives and respective families want to keep their loved ones alive is that we just don't have 'death' in our culture. It's full of dark thoughts, tears, Grim Reaper associations. Rather than how a lot of other countries view it - as something beautiful. The British education system should have as part of their curriculum classes on the culture of death, how if you love someone you don't do the selfish thing in trying to prolong their life. You let them go. We are spirits inhabiting a human body - we are not 'the body' - our spirit, or soul whatever - is the essence of that person and will stay with us in death as in life. My Dad passed in 1992 and I think of him everyday, talk to him, miss him - but I'll never lose the essence of him. And that is a beautiful thing.

    I recently did a Death Workshop, where we got to think about our own obituaries, composed one. Planned where, if poss, we'd like to die, who we'd want there etc. How we wanted the service, if there was one, what music, who'd be invited, what the guests should wear. And I think this is what we should be able to discuss with our loved ones, just like we discuss names of babies, where we'll give birth, and so on, it is a certainty in all our lives. Why is it such a taboo subject?

    Fliss - St Just, Cornwall

  • Programme Transcript - Withdrawing Treatment

    BRITISH BROADCASTING CORPORATION

    RADIO SCIENCE UNIT

    INSIDE THE ETHICS COMMITTEE



    RADIO 4

    TX DATE: THURSDAY 28TH JULY 2011

    PRESENTER: JOAN BAKEWELL

    CONTRIBUTORS: FIONA RANDALL
    ROB GEORGE
    DEBORAH BOWMAN

    PRODUCER: BETH EASTWOOD





    NOT CHECKED AS BROADCAST

    Bakewell
    Advances in medical care can bring new ethical problems with them. This week Inside the Ethics Committee shifts its focus from the dilemma of patients to the issues that exist for medical staff when the terminally ill decide they want to stop their treatment. We consider two recent cases: That of Tom and that of Dennis. First Tom. About two years ago he had a hip operation and afterwards noticed his voice was very quiet. He proves to have pneumonia but his breathlessness persists and he has trouble sleeping. There are more tests and finally he sees a neurologist. His wife, Daisy, goes along with him and recalls her reaction.

    Daisy
    He examined him and although I'd seen him all the time dressed and undressed when he took his shirt off you could see the muscles at the back of his neck had almost gone, that was in a very short space of time.

    Bakewell
    Further tests follow. Finally in the autumn of 2009 a diagnosis is made: Tom has motor neurone disease; it is incurable and fatal. His wife Daisy:

    Daisy
    I was just sure that I'd be ready for whatever they said to us. Well obviously I wasn't ready for it because I just really fell apart and the nurse was just wonderful, she was just there straightaway saying - you're not on your own, we will help you through this. And you think there's nothing that can be done. There's not treatment, there's no cure, so this is it really.

    Bakewell
    Several weeks earlier Tom was prescribed a mask to help him breathe at night. The process is called non-invasive ventilation. The use of this mask is relatively new in motor neurone disease, only in July of last year did NICE - the National Institute for Health and Clinical Excellence - give their approval, saying it can improve the symptoms and hence the survival of those with the illness and its use is much welcomed. Tom's palliative care doctor:

    Palliative Care Doctor
    His main symptom was a wasting and a weakening of the muscles of breathing, so he was finding it over time increasingly difficult to breathe. He was having a build-up of carbon dioxide which was giving him the symptoms of sleepiness in the daytime and he'd been started by the motor neurone disease team on non-invasive ventilation.

    Daisy
    Just before he was going to go to sleep we would put it on and it's a rubber mask, it fits over the nose and round the mouth, and it has a strap that goes round the back of the head, which is not very comfortable. It's attached to a machine.

    Bakewell
    The mask forces air into Tom's lung and then removes the waste products - carbon dioxide. It makes a big difference - he now sleeps better and is less tired during the day. Time goes by and Tom's condition grows steadily worse. By the spring of 2010, scarcely a year since he noticed anything was wrong, his muscles have weakened further, particularly the muscles he uses to breathe and swallow. He's hospitalised to have a tube surgically fitted so that he can fed directly into his stomach. Then he goes home to Daisy. But over the next few months Tom's condition deteriorates further. Together he and Daisy talk about what's happening.

    Daisy
    In the morning - on the Sunday morning - he took the mask off and he said: "I can't breathe at all and I'm going to die." And I said, in my usual fashion: "No you're not and you're not going to do it today, you're not going to die today. So we'll put the ventilator mask on in the day, just to see how you are through the day." So we did but he couldn't take the ventilator mask off long enough to take a breath and speak, so by this time I was giving him a pen.

    Bakewell
    The palliative care team are alerted and come to see him. Daisy is with him throughout.

    Palliative Care Doctor
    Even in the short period of time - a few seconds to take a sip of water - he'd become very panicking with his breathlessness, needing the mask to be put on straightaway.

    Daisy
    The nurse could see straightaway that really this was [pause] the beginning of the end.

    Specialist Nurse
    Tom couldn't speak, he couldn't swallow, he was struggling getting in and out of bed, he actually communicated, writing down on a pad, and said I've had enough, I just don't feel that I can cope any longer - written words along those lines.

    Daisy
    These were all the notes that he wrote. "Let me sleep." "I want to die." We were sitting either side of him on the bed and he was reaching for the ventilator mask and she said you know you can't just do this, it would be very distressing if you took the mask off and you don't know how long it would be.

    Bakewell
    The specialist nurse takes Tom's request seriously. Sedatives can ease his symptoms and distress when the mask is removed but she needs to know what he thinks.

    Specialist Nurse
    I discussed the options open to Tom, which were the options of withdrawal of treatment and withdrawal of ventilation. He wrote down straightaway: "Yes, yes, yes I am ready to come off my ventilator."

    Bakewell
    The team assesses Tom's mental capacity on several occasions to check he's of sound mind to make this decision and conclude that he is. Earlier in his illness he'd filled in an advance decision, sometimes called a living will, expressing his wishes for the end of his life. Daisy knows that.

    Daisy
    He had always made it clear in his advance decision, it was quality of life and he was not going to be kept alive mechanically and that was really what I felt we were doing at that stage because if he hadn't been on the ventilator mask he probably would have died more quickly.

    Bakewell
    Now we take up the case of Dennis who was diagnosed with motor neurone disease last summer. By early this year he's using a mask to help him breathe at night, having chest infections and being fed by a tube into his stomach. Both Tom and Dennis are warned they may slowly become dependent on the mask but are told that they will be given support towards the end if they wish to stop using it. Dennis is admitted to hospital with a second chest infection, he's attended by the palliative care nurse and the specialist nurse and his wife, Mary, is with him.

    Specialist Nurse
    He was confined to bed because he was very weak. He was on the mask continuously. Talking was very difficult because he was trying to talk through a mask with a machine attached to it that was quite noisy. He was very tired and he felt that his breathing, despite the mask, was very hard work.

    Palliative Care Nurse
    We asked him to actually take it off to see how long he could manage without his mask. I could do nothing but describe it as a goldfish out of water gasping for air. So he was having to try and get to the toilet with the mask on or take the mask off and quickly get to the toilet which just wasn't happening so he was having to use a commode and bottles in bed, which to him was not acceptable. So he was very clear that this wasn't the way to live and that he had to stop it.

    Mary
    I remember my husband said I've had some good news but you won't think so. And with that the palliative care team came to have a word with me and explained that he wanted to have the mask removed. I said is this all above board, is this ethical, is this - is this assisted suicide basically? And they said no. And they put my mind at rest. I felt numb actually.

    Specialist Nurse
    Having those discussions around end of life and withdrawing treatment I'll be honest I found very difficult because it's something out of the ordinary, some people may interpret this as ending somebody's life, possibly assisted suicide. That is the key reason I think that I actually spoke to my colleagues to reinforce that yes what was discussed was okay and legal.

    Bakewell
    This is true - Dennis and Tom both have the right to stop using the mask, even though it's keeping them alive. Patients across the country exercise this right to stop treatment every day in all sorts of contexts. For the palliative care doctor stopping the mask is no different from the requests he gets from some of his lung cancer patients.

    Palliative Care Doctor
    I support a number of patients who decide the side effects of chemotherapy outweigh the potential benefits and we continue to manage their symptoms but they know that their cancer will kill them in the end.

    Bakewell
    Ethical unease arises because of the period of time over which the refusal takes effect.

    Palliative Care Doctor
    The short time relationship between choosing to stop the treatment and dying makes it for some people too real. However, the patients who choose not to have dialysis, they may live for one to two months knowing that the choice not to have dialysis has been what's led to their death. In the case of motor neurone disease if patients stop the ventilator it's usually a short period of time over minutes to hours.

    Bakewell
    And Dennis and Tom are both conscious and able to articulate their wishes to stop treatment. They share this with their wives - Mary and Daisy. Now to discuss this with me Dr Fiona Randall, who's a consultant in palliative medicine at the Earl Mont Batten Hospice, the Isle of Wight, she's written extensively on philosophy and the ethics of palliative care; Rob George, Professor of Palliative Medicine at King's College, London and Guy's and Thomas' Hospitals; and Deborah Bowman, senior lecturer in ethics and law at St George's University in London.

    Let's start Deborah with you and sorting out the law, what is legal?

    Bowman
    Well we've already had it explained to us that a capacitous patient can decide at any time that he or she no longer wants treatment. What might be helpful is to think a little bit about the law in relation to end of life care and quite likely it's been said that assisted dying or assisted suicide in this country is unlawful. However, there are circumstances where it's legitimate to withhold or withdraw treatment. And it sounds like that's one of those circumstances that we're talking about today. It's often expressed as the difference between, for example, giving somebody a lethal injection or a fatal overdose as compared to withdrawing treatment such as a life support machine or not prescribing an antibiotic for a patient who develops a chest infection.

    Bakewell
    Fiona Randall, philosophically both end in death and it's a very fine distinction isn't it?

    Randall
    I'm afraid I don't see the distinction as fine in that way because in the cases we've just heard about with Tom and Dennis what they are doing is refusing a treatment which is artificially prolonging their life, that is to me entirely morally different from assisted suicide which is to take a deliberate step with the intention to end your own life by means of taking a lethal medication - intention and cause are quite different. In one case the illness is causing death and in a second - assisted suicide - a lethal medication is causing death and that was everyone's intention. So to me they're quite different.

    Bakewell
    Are you surprised that they're often seen approximating one to the other by just ordinary human beings?

    Randall
    No I'm not surprised at all because it requires some thinking through to perceive the difference.

    Bakewell
    Rob George, both Tom and Dennis are of sound mind and are making this decision while they appear to be quite able - alive, very much alive - how much does that matter?

    George
    They're having interventions which are postponing their death and if you remove the impediments to dying, and the ventilator's an impediment to dying, then actually you're allowing the disease to proceed as it would normally do. The fact that someone's very alive is great because it means you can live till the moment you die. And for us there's a clear distinction about maintaining quality and maintaining an ability, if possible, to interact with one's surroundings whilst recognising that the physical event of dying is going to be something that happens at some point. And in a sense the idea that we are no longer postponing that death is what's happening in these two cases but at the same time we've recognised that additional life has been gained because we've fended off that death with a particular intervention.

    Bakewell
    It's a nice concept, isn't it Fiona, that we should live as much as we can until just the very moment of death and it does seem that medicine is tending in that way. So their being very alive doesn't contradict any of the decisions?

    Randall
    No not at all. The fact that they are very alive and can think for themselves and make their own decisions is seen by most people as a bonus.

    Bakewell
    Rob George, is it unusual that two people like Tom and Dennis, who have capacity right to the end of their life, is that unusual or do you find that quite common?

    George
    It depends upon the diseases that people have. If you're looking at somebody with cancer or some systemic disease, which is an overwhelming one, where there may be alterations in consciousness, then you may have somebody process of dying being a gradual withdrawing from the world, which is happening over the time of days, weeks or even months. Whereas with these patients it may be a relatively short period and I think that the proximity of the decision no longer to continue to live and the event of the death, when they're close together you then interpret that as what I did caused the death, which of course it didn't.

    Bakewell
    Does that have any philosophical significance - the closeness does seem to be relevant doesn't it?

    Randall
    It's relevant emotionally but not logically. These people die because their breathing function has failed and it can no longer support life. The cause of death is the illness - the fact that the patient actually can't breathe.

    Bakewell
    Rob.

    George
    A very good example that I come across all the time and in senses have experienced myself is that if you give a patient an injection for symptom control or something and they die within a few minutes then it's almost impossible emotionally not to think you caused that death.

    Bakewell
    Deborah, the interesting situation, them being so articulate as they are, is that they speak of their quality of life and who judges quality of life?

    Bowman
    The person who judges the quality of life is the person involved, if he or she has capacity. I would say in a situation like this where you have somebody telling you that their quality of life is such that they don't particularly want to continue, that in itself is sufficient.

    Bakewell
    Rob.

    George
    I think that's right. Of course the fascinating thing is as we all age the goal posts move and the quality of life now that I'm grateful for when I was 21 and playing competitive rugby would have been a life not worth living. And the fascinating thing of course is that - because this is perceptual - that can change incredibly rapidly. And actually interventions of clinicians like ourselves to help people reframe the experience they're having is an important contribution to helping them with their suffering.

    Bakewell
    Good. Well let's move on with the story because by now both Tom and Dennis are completely dependent on their ventilator masks and have made clear they want to stop using them. The medical team treating them both have individual difficulties with this. Tom wants to die at home with his wife Daisy, the palliative care doctor and the specialist nurse will all be present when the mask is removed. The doctor discusses with Tom what this involves.

    Palliative Care Doctor
    That discussion entailed talking to Tom about the use of sedative medication which reduces anxiety and reduces distress and that we would start this medication in advance of taking the mask off so that he was relaxed and he was not distressed. And then when the mask was removed there would be medical and nursing staff on hand should he develop any distress. It was making it absolutely clear to Tom that our priority would be keeping him comfortable at the end of life.

    Bakewell
    His wife, Daisy, is at his bedside.

    Daisy
    It was decided that it would be the Friday. The sooner the better really as far as Tom was concerned. At this stage we had carers in to wash him, it was like our home was a hospital, but it was better than a hospital because he had so much individual attention. We were in and out, by this time we'd managed to get hold of my daughter and she came home, my son was there, he said we're just going to stay now. So my son would watch rugby with him, he'd set up his iPad on the bed. We have two dogs, they were in and out. It was just as comfortable as it could be and he was still writing me notes. I've got this one here which says: "Have you watered the tomatoes?" And just - he was just trying to keep things as normal for us and for him as possible.

    Bakewell
    But it is their own GP who conveys his uneasiness with what is happening.

    Daisy
    The GP was coming regularly and talking quite a lot to him and then coming and talking to us - my son and daughter were there - and asking our opinion about what was Tom's wishes.

    Palliative Care Nurse
    He was not comfortable with the actual process of withdrawal of ventilation but he also discussed the issues of culture and beliefs and I think he didn't feel comfortable to be actually controlling the situation in relation to taking the ventilator mask off and switching the machine off.

    Daisy
    The GP did keep asking him - will you not go into hospital? And I think he thought it would be easier because it would be sort of out of his control if he was in hospital and not at home. I think he just wanted Tom to slip into a coma and die naturally, he didn't want any interference at all - this was what you gathered from the way he was.

    Palliative Care Doctor
    And he sought advice both from his defence union and even from the General Medical Council. He was reassured by both of those organisations that this was perfectly acceptable but he still felt, personally, uncomfortable with the idea of being there, of taking the mask off.

    Daisy
    It isn't something that any of us wants to happen at all but he has decided that when there's no quality of life - I said he is alive in the other room and he is able to write his notes and communicate with us but that is all that he's able to do and he hated just being so dependent.

    Bakewell
    When the moment comes Daisy, who'd been supportive of Tom throughout, finds it almost too much when Tom writes out what he wants to happen.

    Daisy
    I knew that I would be there with him in the room and I would be holding him and talking to him but until he actually wrote that down I didn't know that that was what he wanted. But yes I was prepared to do it. So the consultant said we'll do it together, we'll stand either side of him and we'll both take the ventilator mask off and the machine will be switched off at the same time.

    Bakewell
    In contrast Dennis' last days are spent in hospital on a respiratory ward. It's spring this year and planning goes ahead with Dennis himself leading the arrangements. The palliative care nurse:

    Palliative Care Nurse
    We spoke at length about how we would manage his symptoms and how we would start a pump with some medication to calm any anxiety or breathlessness experience down and how we could give him extra top ups of that if and when needed through the process and that we would be with him throughout so we could respond rapidly to his situation. We talked about the uniqueness of picking the day that you die, which is very unusual and he talked about that it was very weird. He had a very dry sense of humour and said that he didn't believe in God, when you're dead, you're dead but he liked the fact that he could pick his time and have control over it. So there was quite a bit of bantering going on around that time, despite the fact it was a very unique situation.

    Bakewell
    Again there is discomfit among some of the staff looking after Dennis.

    Palliative Care Nurse
    When I approached the ward sister and the staff nurse looking after him to say this is what he's wanting to do and this is what we're going to facilitate he - they were very distressed by the concept that that seemed wrong. There was a very big concern that it wasn't legal and that we were going down the route of euthanasia. It was the correlation between removal and death that seemed to be frightening people and they did seem genuinely concerned that they would be in trouble and their registration would be at risk and legally we would be in trouble.

    Bakewell
    Nonetheless the plans go forward.

    Palliative Care Doctor
    Dennis, despite this being an extremely serious and grave situation, maintained an amazing sense of humour and wanted to choose the day that he died on, he even wanted to be specific about the time, so he ordered us to come back at 10.30 on the Thursday morning and not to be late.

    Bakewell
    His wife Mary gets the family together.

    Mary
    Luckily his parents were able to visit on the Wednesday, his brother and our daughters and the daughters and his brother and myself were with him on Thursday.

    Bakewell
    Well now we've heard that medical staff object, so Deborah are medical staff entitled to refuse to be attendant on events like this?

    Bowman
    There are some circumstances where medical staff can express a conscientious objection, this isn't one of them but for example The Abortion Act provides that medical staff don't need to be involved in terminations of pregnancy, save for some particular circumstances. There is a professional obligation to refer to a colleague if one has a conscientious objection. And it would be unusual for conscientious objection to be cited in these sorts of circumstances but that's not to deny that people will feel differently, just as patients feel differently, doctors, nurses and others feel differently.

    Bakewell
    How would you deal with it Fiona?

    Randall
    There are two things that are important here: firstly, everyone's assuming that the act of removing the mask is an act that causes death, what they've lost sight of is that they are simply stopping a treatment - non-invasive ventilation doesn't happen without positive application of the mask, making sure it's fitted and making sure the machine is continuously working.

    Bakewell
    But human behaviour, human life, is often ruled by the heart and the impulse and the intuition as much as by logic and how then do you deal with people's anxieties when they are trained medics but nonetheless have this running conscience?

    Randall
    Well I think that's the second point, I think that this GP needs help to understand that what you are simply doing is not continuing something which is artificially prolonging this patient's life and as Rob said earlier, is actually putting off death. And the other thing that did cross my mind about this GP is if this GP is really uncomfortable with this, even though I'm not sure you can conscientiously object, is the GP the best person to be doing it if he feels so uncomfortable?

    Bakewell
    Rob George, we've heard the anxiety that was expressed by medical teams, that they would lose their accreditation and that kind of thing, surely the shadow of Dr Shipman hovers over all this kind of thing - the popular image?

    George
    I think that's right. There's a great deal of confusion about when you actually physically do something. For example, if somebody said listen I don't want to take insulin anymore and you say well you're going to die from the diabetes then aren't you and they say, well I'm just not going to do it and I no longer prescribe the insulin, in other words I don't pick up a pen and write the prescription, that kind of feels like I'm not a moral agent in this at all and indeed you're not a moral agent because the patient's saying keep out of my space. What's happening here is the patient's doing exactly the same thing, they're saying do you know what, get out of my space, take this mask off me because my motor neurone disease is now going to kill me and that's a choice that I've taken. And the fact that we've had physically to remove the mask, because we've taken a physical action, makes it feel something different and I think the intention is really important here because none of the clinicians here intend that the patient dies, they intend that the patient is no longer interfered with - that's where the intention is.

    Bakewell
    Fiona.

    Randall
    The professionals concerned are worried about their registration, I think they're expressing the wrong worry, if they actually go on forcing a treatment on a patient who doesn't want it then they will bring their registration into doubt by not complying with the patient's refusal to continue with the treatment.

    Bakewell
    Deborah, does the law have something to say about that?

    Bowman
    Absolutely, if you continue to treat somebody against their wishes it is an assault or a battery, depending on the way in which the law is interpreted. It's very interesting, just picking up on something that Rob was saying, I think actually one of the things that makes this so different as well is that patient can't himself remove the mask, he can only do it with the assistance and support of the clinical team and it's not just about removing the mask, it's about the sedation, it's about supporting the wife, it's all of those other things. And therefore there is a sense of involvement and that becomes mixed up with causation.

    Bakewell
    Now both these patients - Tom and Dennis - are having sedation to ease their restlessness. Is the sedation likely to bring their death closer? Rob.

    George
    Most people would say you're sedating somebody they're bound to die quicker. The paradox is actually if you sedate somebody they may well live longer. By reducing the drive to breathe you often make breathing more efficient and they may well be able to talk and communicate and be comfortable during that period.

    Bakewell
    Fiona.

    Randall
    Rob has just explained a bit of specialist knowledge, the difficulty is that most doctors won't have that specialist knowledge, so most doctors will then tend to think that if they sedate the patient they will reduce respiratory drive and the patient will in fact die quicker. And this of course further increases people's confusion.

    Bakewell
    The one thing that both patients do retain - and it's rather eerie - is that they believe they're deciding the day of their own death.

    Randall
    Because it's so likely that death will ensue when their request is granted and the treatment is stopped they have a very unusual power to decide which day. It's interesting that they both deal with this so very well.

    Bakewell
    Rob.

    George
    Well there is a sting in the tail here of course because by the fact of no longer interfering with what's going on the process may actually take a lot longer than we anticipate. And I recall many, many years ago looking after a patient in whom we were absolutely certain they were going to die, they were on an intensive care unit, ventilated, we stop the ventilation, we stopped the support of the heart and the circulation and the patient settled down, the patient continued to breathe and the patient eventually woke up and went home.

    Bowman
    These cases have a name in the ethics, they're called Lazarus cases.

    Bakewell
    Well let's move on with the story because we reach the eve of Tom's final day. Tomorrow his mask is going to be removed. Unable to use his arms anymore he asks his wife to shave him. He's having sedatives to ease his discomfort. The palliative care doctor comes round and gives him more sedative. Daisy is worrying about removing the mask.

    Daisy
    He came into to talk to me and at that stage I said: "Do you think I can do this?" He said: "I think you can. You're a strong person and it's the last act of love you can do for him." So you have to carry that forward and think that's what you are doing, you're doing it for him.

    Bakewell
    It's the next day. Tom's son and daughter decide not to be present in the room.

    Palliative Care Doctor
    It was a Friday afternoon, it was a very nice sunny day and I drove over to the patient's home. The GP, myself, the nurse from the community and the nurse from the local hospice - we were all present along with his wife. Having had all the discussions with Tom and having it very clearly stated from him that he wanted to go ahead we described to him that we would give him a small dose of a sedative medication and that would make him feel more sleepy.

    Bakewell
    The GP is present in the room.

    Palliative Care Doctor
    Although the GP didn't feel he could be actively involved in the process he wanted to be present to support the patient and the family but he needed additional support and that was from myself to lead the administering the sedative and the removing of the mask.

    Bakewell
    But the family don't feel supported.

    Daisy
    It was almost as if he wasn't there, he was standing back, we were all round the bed and he was standing at the foot and a little bit away. He just said how sorry he was but he didn't say anything about the whole procedure really, as if he hadn't wanted to be there but he had to be there because we had to have a GP there.

    Palliative Care Doctor
    We gave Tom a small dose of sedative medicine and he did become more drowsy, he did become more sleepy.

    Daisy
    He reached for the pen and they thought he was going to write me a romantic little note, so they all left the room and I came out and they looked expectantly and he had written, as it says here: "Will you put my teeth in?" So we did.

    Palliative Care Doctor
    When Tom seemed very settled there was a point where his breathing was very shallow, it was clear at that point that if the mask was switched off the shallow breaths would not sustain his life. His wife Daisy removed the mask. Tom's breathing slowly became shallower and shallower.

    Daisy
    I expected instant I think and it wasn't. The doctor explained it would possibly take a few minutes. And it was 10 minutes really - a very long 10 minutes.

    Palliative Care Doctor
    And it was clear at that point that Tom had died and had had a good death.

    Bakewell
    Dennis will die in hospital. It's the day before the removal of his mask.

    Mary
    When we walked into the room we didn't even have to ask him the question - he said straightaway if you're asking me the same question then I'm going to say yes, I want the mask taken off and I know that I'm going to die if I take the mask off and I want to do it tomorrow at 10.30. So we got here early and sat with him and he seemed very bright and breezy that day and I thought what is happening here, what is going on. But he was very calm, quite okay about it.

    Palliative Care Nurse
    It was a strange day in the sense that as usual we came to work with a sense of knowing something different was going to happen that day but quite clear it was the right thing to be supporting him doing that. We got down to the ward and the palliative care doctor, myself and the motor neurone disease specialist nurse and we went into the room to see him. His family was there, which was his wife, daughters and his brother. The team were a wee bit late arriving. He told me off for being late because it was 10.31, which was very typical of Dennis. He was very clear that we were to continue on. So we spent a bit of time trying to get an intravenous access for him, so that we could give him sedation - topped up quickly if he needed it, so keep him comfortable. I remember that being a very difficult thing to do because we were being watched by family, which puts you under pressure. And then we gave him an extra kind of dose of sedation to help him get more sleepy and we stood back and waited.

    Bakewell
    Even so it takes quite a while for Dennis to become drowsy.

    Palliative Care Doctor
    I stroked his arm and asked him how he was feeling and he opened his eyes and told us that he was still feeling fine but he was still awake. So we waited.

    Palliative Care Nurse
    A few times he shut his eyes, so I went up and bobbed down and kind of touch him and he opened his eyes and then just nodded and then shut his eyes again. And then a few minutes later I checked with him how kind of awake he was and he mouthed he was still here, which was very typical of Dennis as well. So we then gave him a little bit more medication because he wanted to be more sleepy, which was more successful.

    Bakewell
    After a couple of hours Dennis is drowsy enough for the team to switch off the ventilator and remove the mask. They expect his death to follow soon after but as Mary recalls it takes a lot longer.

    Mary
    We sat there for hours, yeah and my younger daughter - she said: "Why is this happening, as he's managing to breathe on his own?" But they said well he's breathing but he's being medicated, so as not to be struggling for breath and being agitated. So it just sort of carried on really.

    Palliative Care Nurse
    Our experience is people die within a few minutes or our longest experience was an hour with taking the mask off. But we went way beyond an hour and we were almost kind of entombed in a room not really aware of what was going on on the outside.

    Mary
    My daughters were reminiscing about where we'd been, what we'd been up to, what dad had said and my brother-in-law kept nipping out for a cigarette and then coming back and saying: "Is he still here?" And I kept saying: "Are you supposed to be somewhere else?" And one of them had got a child to pick up and they said no, no, it's fine. I mean it seems awful to laugh about it but that's how it was.

    Palliative Care Nurse
    We were conscious by about half past two that things were sort of changing.

    Mary
    And then he just went, so mm.

    Palliative Care Nurse
    When he died I felt very overwhelmed and was very tearful and showed my tears. There's was lots of hugs in the room but I felt that we'd done our job well and it was something that I was very proud of.

    Bakewell
    Dennis died four months ago. The nurses who were uncomfortable about his request turned down the opportunity of a debrief at the hospital. Last year NICE developed guidelines recommending the use of these masks to reduce the symptoms of breathlessness in patients with motor neurone disease. The palliative care team expect their use will become more common.

    Palliative Care Doctor
    Over the past two years we've been involved in four cases. To put that into context: over the last 10 years before that I hadn't come across it.

    Palliative Care Nurse
    For those who tolerate the mask it works really well and it definitely buys them quality of life, if not a bit of time as well. I think my concern for the future is that we're going to use this mask more and more often to manage symptoms, so more and more people are going to possibly want to have control over when they want the mask taken off because they are going to reach a point when they need it 24/7 and for some people that might be acceptable but for many it won't be. And I think as a professional group of people we need to sort of look at why we're not comfortable with it and how we then get comfortable with it because it's not something that's going to go away.

    Bakewell
    Rob George, first of all why did it take so long for Dennis to die?

    George
    Well I think you see both in Tom and Dennis two ends of the spectrum. Tom's got very little residual capacity to breathe, so you remove the ventilator and he dies very quickly. With Dennis it's different, he's got residual capacity to breathe and indeed what's happened is essentially by removing the ventilation we are just witnessing the closing hours or could have even been days actually of the process of his motor neurone disease. So that's proving almost that the sedation is immaterial in the nature of the death, the death is a result of the disease.

    Bakewell
    But in emotional terms Fiona, it's also suggesting to the people who are around his bedside that this is not quite as it was anticipated, is that acceptable Fiona?

    Randall
    Whilst the patients and the families knew that there would come a time when they might not want the mask anymore knowing that intellectually is very different from being able to predict one's own emotional reaction when that time comes. And the other thing that everybody would probably have understood or needs to understand is that this mask might have to be removed for other reasons. For example, in some patients it causes very painful facial ulceration, so it isn't just that the patient might no longer want the mask, it's that they may in fact be unable to tolerate it.

    Bakewell
    But let me turn to Deborah here because the medical team have expressed concerns and reservations, what is the future - I mean should they be becoming doctors and nurses at all?

    Bowman
    There was a very controversial paper in the British Medical Journal that expressed the view that opinions of conscience have no place in medicine. I think the majority disagree with that - doctors are as entitled as anyone else to hold views and those views will differ. I think, for me, it's about reflecting on the source of those views but also actually then to think well, how am I going to manage my personal opinions in my professional life and that actually is as much of training and development as learning the physiology and the anatomy. I think in good teams you can have a divergence of opinion and there will be opportunities for expression of that.

    Bakewell
    Right well we've heard that this use of this mask for motor neurone disease, which is admittedly a very rare illness, is likely to get more common and therefore of course the dilemma will crop up more frequently. So what's the ethical way forward? Deborah Bowman.

    Bowman
    I think we have to be brave and honest. I think teams have to think pre-emptively about this particular treatment; how it fits into the broader context of withholding and withdrawing treatment and really come up with some very practical guidance and there is some excellent practical guidance already out there on how these situations are managed. But being honest, being brave and being respectful in discussions about how to handle this particular situation.

    Bakewell
    Fiona Randall.

    Randall
    With regard to the mask and motor neurone disease, given that motor neurone disease is an uncommon illness, this situation's not going to arise very often, so we need to develop pockets of expertise to deal with the specific situation. But more broadly we need to educate healthcare professionals to understand that we are increasingly artificially prolonging life, therefore there is a continuous need to balance the benefit of the life prolonged against the burdens and the risks of the treatment and constantly to review with the patient - is this something that they still want to be continued.

    Bakewell
    Rob George.

    George
    I think that's right because in some senses we assume that duty of care is that we carry on trying to keep somebody alive. I think there's a time honoured duty of care is that we stop trying to keep them alive and actually for juniors to understand that their stopping the treatment is not their causing the death, it's the disease that is killing them. And then finally of course we can't stage manage death and we've seen that very clearly with Dennis.

    Bakewell
    Let's then listen to the coda to the story.

    Palliative Care Doctor
    To know that you're going to see somebody and know that they're going to die that afternoon is an unusual feeling but it's an immense privilege knowing that you're doing the best you can as a doctor to make sure that they're as comfortable as they possibly can be at the end of life.

    Bakewell
    But for the wives of Tom and Dennis a certain reticence prevails.

    Daisy
    The few people that I have told have been sympathetic and supportive. Then recently I told someone who I imagined to be a friend and shock, horror, revulsion, disapproval - everything was written all over her face. She just wasn't comfortable with talking to me any longer.

    Mary
    I haven't actually said that the mask was removed and it was arranged really. I felt embarrassed that people would think she was instrumental in his death. Three months down the line I might be able to.

    ENDS

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