The effect of the Shipman murders on clinician attitudes to prescribing opiates for dyspnoea in end-stage chronic obstructive pulmonary disease in England

摘要

Introduction: Harold Shipman, a general practitioner (GP) working near Manchester in England, is thought to have killed 250 of his patients by diamorphine overdose between 1975 and 1998. Opiates are recommended for relieving dyspnoea in end stage chronic obstructive pulmonary disease (COPD). Little is known about the effect of the Shipman case on clinician attitudes to prescribing of opiates in advanced COPD. Subjects and methods: Focus groups were held with a total of 39 health professionals in primary (n = 3) and secondary care settings (n = 2) in two sociodemographically contrasting areas of England. Results: Participants identified that the experience of dyspnoea in end-stage COPD was often distressing for patients, their families and their professional carers. Whilst opiates were recognised to be effective in relieving dyspnoea, the Shipman case, and associated fears of litigation, was identified as the key barrier to prescribing. Whilst this was seen as a particular problem within primary care settings leading, for example, GPs to admit patients to hospital rather than prescribe opiates, it was also considered an issue within acute hospital settings. Of particular concern to participants was recognising when an exacerbation was 'terminal' and hence opiate prescribing appropriate. Conclusions: There is evidence to show that opiates are effective in managing end-stage dyspnoea in COPD without hastening death. However, participants did not perceive this to be the case and expressed considerable anxiety about appropriate prescribing in this situation. Given the significant burden of dyspnoea on patients with advanced COPD, there is an urgent need for appropriate training to increase clinician confidence regarding opiate use in this patient group which is sensitive to the concerns raised by the Shipman murders.