A Scottish neonatologist who injected two terminally ill babies with the muscle relaxant pancuronium has been cleared of mercy killing by the GMC...
A Scottish neonatologist brought before the General Medical Council (GMC) has been cleared of mercy killing.
Counsel for the GMC had claimed that Dr Munro's actions were 'tantamount to euthanasia'. Yet yesterday the GMC Fitness To Practise panel ruled that his actions - injecting two terminally ill, premature babies with pancuronium (a muscle relaxant) - were motivated by his desire to relieve their perceived suffering rather than by an intention of hastening their deaths.
Baby Y was born on 20th June 2005, two weeks premature, and had pulmonary hypoplasia (under-developed lungs). After the decision to withdraw treatment had been made, the baby had been given to his parents to hold.
Once its breathing appeared to have stopped, both the nurse and parents believed that death had occurred. Yet, when he examined Baby Y to certify death, Dr Munro found its heart was still beating faintly. The baby then commenced 'agonal gasping'.
Agonal respiration is the abnormal breathing pattern sometimes seen in the last few minutes of life. It describes shallow, slow and irregular inspirations, followed by irregular pauses. Gasping sometimes also occurs, along with strange vocalisations and bouts of myoclonus (muscle jerks or spasms). It is due to cerebral hypoxia (lack of oxygen to the brain).
Dr Munro then took the decision to administer pancuronium. He said he chose this drug after reading a recent article in a medical journal and believed its use was ethical and acceptable in this situation. He explained to the parents that the drug was to be used to ease the suffering but that one of the consequences of its use may be to hasten death. The parents were apparently happy with this. Dr Munro denied that he had tried to hide his actions by not recording his use of pancuronium in Baby Y's notes.
Baby X, born more than three months prematurely on 5th December the same year, had a brain haemorrhage. Again, once treatment had been withdrawn and the baby appeared to have died, Dr Munro found that it was still alive with a faint heartbeat.
Describing his actions as the child began agonal gasping, Dr Munro said that he tried to explain that this was simply a reflex although he felt in his heart that the baby was distressed. After discussion with Baby X's family, he again made the decision to administer pancuronium and death occured soon after. He again denied that his failure to record this in the the notes was an attempt to hide his actions; however, he did concede that his note-taking had been inadequate.
Giving expert evidence at the hearing, neonatologist Professor Ian Marlow gave the opinion that it was unlikely these particular babies had in fact been suffering distress. He added that, although Dr Munro acted from the 'highest personal motives', his use of pancuronium could not be justified.
Speaking in Manchester after the verdict had been announced, Dr Munro issued a statement: 'I hope that today's decision will promote further consideration of the treatment of neonates and end-of-life decision-making and that this, in turn, will lead to clearer professional guidance for doctors, better patient care and greater support for parents'.
Sheila McLean, professor of medical ethics at Glasgow University, said: 'In the last 20 years the capacity to deliver live premature babies, who often have constitutions incompatible with life, has expanded. Doctors are now confronted with many more dilemmas than they were 20 years ago. It is imperative that doctors are able to act within guidelines that are clear to them'. And Graeme Laurie, Edinburgh University's Professor of Medical Jurisprudence, commented: 'The GMC in Dr Munro's case accepted there was a lack of professional guidance. We need more guidance, and the responsibility for that clearly falls on the GMC'.
In response to the GMC verdict, Dr Roelf Dijkhuizen, medical director of NHS Grampian, the trust Dr Munro works for, revealed that a new protocol for all end of life decisions has already been put in place. With regard to pancuronium, the new policy states that pancuronium should only be given to babies who are either on a ventilator or who are already on the drug: 'We believe these measures will avoid similar incidents arising in future...Patients and families can be reassured that NHS Grampian remains absolutely confident that the quality of care in the neonatal unit is of the highest standard'.
CNK Campaign Director, Dr Peter Saunders, comments:
Pancuronium is a muscle relaxant, not a pain killer nor a sedative. By giving 23 times the usual therapeutic dose, Dr Munro clearly intended to end the lives of the two neonates under his care by paralysing their respiratory muscles so that they could no longer breathe. Although the GMC has recognised that he would have been motivated by a desire to ease his patients' suffering at the end of life, these desperate acts were unprofessional, unethical and unneccessary. There are more effective ways of dealing with agonal gasping in a terminally ill baby and standard palliative care would have involved pain relief and sedation along with explanations to the parents about the reflex nature of the gasping. It is simply not necessary to kill the patient in order to kill the pain.
This case underlines the need for neonatologists to obtain proper training in palliative care, as emphasized by the recent Nuffield Council Report. It is noteworthy that the hospital has now introduced a protocol supporting the view that pancuronium should never have been given in these clinical circumstances.