Optimal management of dying

The editorial by Gin Malhi and Kalmaldeep Bhui (Reference Bhui and Malhi1) discusses the challenges and supports around terminal illness especially that complicated by a mental illness. It seems there may be three scenarios. 1. People who do not receive optimal end of life care. They are suffering and appropriate palliative care has not been given. This may be the biggest group of people who find their final weeks and months difficult. The answer is to provide appropriate palliative care (and a recent law has made this a right), and not to assist their suicide. 2. Those with so called unbearable suffering. This terminology comes from Dutch/Belgian parlance and is unsatisfactory as a diagnosis and wide open to abuse and error. Many such people may have poorly managed care and optimal care would make their lives bearable. Those not adequately managed by optimal care may fit into category 3. 3. Those who cognitively, emotionally and philosophically want to end their lives regardless of symptoms or illness. Freedom enables people to do and choose what they want regardless of consequences to themselves, collateral damage and moral infringements. This however never means their choice has to be rolled out to the population and become law. People do all kinds of things and it is their own responsibility and not the basis of a cultural, legal , philosophical or moral change for anyone else. Incorrect laws and precedents can cause serious harm to the more vulnerable who cannot defend themselves as Professors Bhui and Malhi point out. Copy cat behaviour, Halo effect and social impact can all influence attitudes and as the Liverpool care pathway showed once started regulation and controls are sidelined.