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Bill Noble

Des Spence asks, are we in denial?

30 Jun, 11 | by BMJ

Des Spence, in his BMJ ‘From the Frontline’ piece, asks the question, “Assisted dying: are doctors in denial?” It turns out that, rather than being for or against legalisation of physician assisted suicide, Des suggests a third, pragmatic position. He suggests that doctors routinely withhold treatment and shorten patients’ lives with the use of large doses of morphine. This he equates to assisted dying. He proposes that we should be honest and accept the principle of assisted dying and engage in the debate about what assisted dying is.

I have no doubt that giving toxic doses of morphine to shorten the lives of dying patients was the practice of many doctors in the past, but I am also quite sure that it is not common practice now. If anything, the pendulum has swung back to a position where analgesic regimes are not only safe, but rather cautious. Certainly we know that many are ineffective. Those of us working in palliative care services know how easy it is to spot the early signs of opioid toxicity and avoid it. Withdrawing and withholding treatment that is futile or irrelevant to dying patients is unproblematic and there is no difficulty in ceasing life prolonging treatment when that is the wish of a competent patient. I only worry about my patients committing suicide if their mental health is in question, but I’m not going to assist any of them.

One of the many interesting aspects of this debate is that there remains a majority of doctors opposed to a change in the law, in spite of the result of opinion polls in the general population. Doctors who deal with a lot of death in their professional lives are particularly opposed to a change in the law. I personally think that we are influenced by some families and carers who express a preference for doctors giving toxic doses of drugs to their dying patients. There is a spectrum from those that just find it impossible to see their relative in such distress to those with more selfish motives. Dying patients are often ashamed of their distress and the upset they bring to others. I know that if the law changed, the culture would swing even further towards devaluing the lives of frail, elderly and sick. I’m not suggesting that incontinence will become a capital offense, but you know what I mean.

Des says that the debate is simply too important to be left to lawyers and politicians. I do think that doctors need to contribute to the debate, but not for the reasons Des proposes. I’m not saying that we doctors have a monopoly on the evidence, but we do see nearly the whole range of human reactions to common place adversity and we do have some messages that society may find upsetting.

Bill Noble, Editor-in-Chief, BMJ Supportive & Palliative Care

Integrating quantitative and qualitative methods – and getting it published

14 Jun, 11 | by BMJ

Bill Noble, BMJ Supportive & Palliative Care, Editor-in-Chief

Describing a study as ‘mixed method’ never felt very respectable or clever. For years we understood that finding the answer to questions about the value of parts of the health service required different kinds of data. The difficulty was knowing how best to put our findings together. Last week the MoreCare Workshop, led by Irene Higginson and Chris Todd, brought together researchers interested in writing guidelines for effectively designing, analysing and reporting mixed method health service research.

The belief of some researchers that only their methodology had a special relationship with the truth posed another difficulty. Depending on their expertise, they were very antagonistic to either ‘reductionist’ or ‘anecdotal’ ways of thinking.  These people might have been the reason why it was always difficult to publish or get grants for mixed methods. Most members of multidisciplinary research teams have some enthusiasm for the other camp’s trade; and so it was with this meeting.

Alicia O’Cathain was the first to confess the sin that turned out to be everyone’s guilty secret –  we had all reported mixed method studies in separate papers, hermetically sealed by methodology in different journals, with hardly a nod to what we knew about the other aspects of the study. We talked about ways of drawing overarching conclusions from the whole study and making a special effort to get that bit published. There’s a problem with word count when it comes to writing up these studies and as the BMJ‘s Domhnall MacAuley explained, what matters most to editors is new insights. A linked series of papers is one way that reporting these studies could go. Certainly this journal would be interested in mixed methods papers.

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