British Geriatrics Society (BGS) statement on the Terminally Ill Adults (End of Life) Bill

In 2024, the BGS published a new position statement outlining our opposition to the legalisation of assisted dying.

Whilst the BGS was disappointed we were not included in the expert witness list, we welcomed the opportunity to provide written evidence to the public bill committee. As a result of our evidence, we were pleased to see an amendment to the TIA Bill that removed ‘medical condition’ from the definition of terminal illness, a change in definition that would help to protect the rights of older people with frailty.

Despite this, the BGS has significant concerns about the TIA Bill as it stands ahead of the second day of its report stage on 13 June. The BGS agrees with concerns outlined by other organisations representing healthcare professionals, including the Royal College of Physicians and the Royal College of Psychiatrists. The following concerns focus on issues specific to older people:

1. Older people and those specialising in older people’s healthcare would be significantly affected by the TIA Bill, but have been excluded from the debate

If AD is legalised, the majority of those impacted will be older people. This is a fact supported by international data from countries where AD is legal. Despite this, older people and the concerns of those specialising in the healthcare of older people have been overlooked during the drafting of the TIA Bill. The BGS pushed for UK experts in older people’s healthcare to be invited to give evidence to the TIA Bill Committee, but none were included. We are deeply concerned that the bill does not address the needs of the group most impacted.

Most older people who die each year have multiple health conditions. Their needs are different to those of younger people dying of a single condition. The presence of other conditions alongside a terminal illness requires the expert knowledge of older people’s healthcare specialists. There are insufficient provisions within the bill recognising the needs of older adults with multiple health conditions.

The bill does not require a person to be assessed for all health, social, psychological, functional, and environmental needs. Instead, it only requires that those involved are satisfied that an individual has capacity and is free from coercion. Introducing a holistic assessment may address treatable needs that would otherwise influence older people to choose an assisted death. This involves looking into all aspects of a person's life to assess whether there are needs that are not being met, that may also be causing suffering. For example, an older person may be feeling lonely or isolated, which can be resolved through referring them to a voluntary-sector befriending service. In geriatric medicine, this type of assessment is known as Comprehensive Geriatric Assessment (CGA) and is the cornerstone of good healthcare for older people. We view it as unacceptable that older people may choose an assisted death due to factors that could be addressed through a CGA.

2. There are inadequate safeguards to protect older people from harm

Older people are at risk of abuse and coercion, and this may not always be obvious to healthcare professionals. Ageism in society may also influence older people into thinking they are a burden and therefore more likely to choose an assisted death. The BGS is concerned by the findings of the Government’s Impact Assessment of the TIA Bill, which highlights that older people are at increased risk of abuse, coercion, and being subtly pressured to end their life prematurely. We are also concerned by international data which illustrates that up to half of people state that being a burden is one of the reasons for choosing an assisted death. Older people often feel pressures associated with getting older, such as requiring care, and the need to give up their home. It is imperative that robust procedures are in place to safeguard older people from harm, and this is currently lacking in the TIA Bill. Provisions are needed that explicitly acknowledge the impact of societal ageism on the choices of terminally ill older adults, and robust training of healthcare professionals is needed to recognise this.

3. The bill does not sufficiently consider the role of healthcare professions other than doctors

Many older people are cared for by a wide range of healthcare professionals, including nurses and allied healthcare professionals. The BGS feels that the TIA Bill is framed around an outdated medical model of healthcare and does not refer to the role of the wider multidisciplinary team, instead focusing on the role of medical practitioners. Many older people will not have a strong or continuous relationship with a medical practitioner, and often a nurse or an allied health professional may take on this role. Senior decisions are not always taken by doctors, and consultant nurses often lead palliative care teams. More guidance is needed on the role of the wider multidisciplinary team and how they would be involved in the assisted dying process.

A survey of BGS members found that over half of respondents would be unwilling to take part in the AD process. We strongly advocate for the right of all healthcare professionals to conscientiously object from taking part in any part of the AD process.

4. The unequal and inadequate provision of palliative and end of life care in the UK is not recognised within the bill

Palliative and end of life care services are under-resourced in the UK, and there are variations in services across the country. As a result, many people who may require these services are unable to access them. Repeated reference is made within the bill to “available palliative, hospice or other care”, requiring a medical practitioner to discuss these options with the patient. The BGS is concerned that older people may be influenced to choose AD because of the lack of palliative and end of life care available. Good-quality end of life care is not currently available to everyone in the UK. We believe improving this situation should be a higher policy priority than legalising AD. Our position statement outlines priorities for palliative and end of life care that should be addressed before assisted dying is legalised.

5. Assisted dying should be a separate service to palliative and end of life care

One of the stated aims of the TIA Bill is to provide terminally ill patients with a holistic approach to palliative and end of life care. However, the BGS strongly advocates for the separation of assisted dying services from the provision of palliative and end of life care. The debate around assisted dying, alongside a lack of public literacy around planning for the end of life, has left many with a distorted understanding of the dying process. BGS members have raised concerns about patients unwilling to take part in discussions around end of life care, as they associate it with assisted dying due to media coverage of the TIA Bill. Patients should not be denied good palliative and end of life care because they fear this will lead to discussions around assisted death. Allowing death due to natural causes at the right time instead of continuing unwanted interventions aiming to prolong life is distinct from the intentional ending of life. Patients need to be clear about this distinction and allowed to make an informed choice without fear of disempowerment or coercion to shorten their life. 

6. It is difficult to predict when an older person may die

The recognition of end of life and treatment decisions towards the end of life are complex, requiring substantial training and experience. Doctors are fairly accurate at predicting when someone has less than two weeks or more than a year, but the timeframe in between is challenging. In older people with two or more conditions and those with frailty, this becomes even more difficult. It is important that MPs consider the significant room for error this may present, which may result in premature deaths or insufficient time for safeguards to be implemented.