Joseph’s Elective Journey in Jersey

I have been hugely excited about my elective. Saying that I am off to Jersey is often an eyebrow-raiser with many expecting some elaborate, distant elective on the other side of the globe. Jersey is very easily accessible from the UK, a short (yet choppy!) ferry trip from Poole landed me on the island in a few hours – with my car too which was an added bonus! Jersey, being an island, requires itself to provide a high level of medical care otherwise patients will be required to travel to the UK for further treatment. This means that I was able to experience a thriving palliative care service on the island comprising of inpatient care in the hospice, community care with Clinical Nurse Specialists, and specialist palliative care in the hospital. Furthermore, Jersey has been in the process of legalising assisted dying. While my views remain largely neutral on this, it is a topic of medical ethics that is fluid, fascinating and bound to dominate our news and healthcare in years to come in the UK.

Aside from all this, Jersey is just a very nice place to visit! A win-win if you ask me.

I liaised with the clinical director (and only palliative care consultant on the island) in preparation for my elective and he was very keen to take me on for a few weeks. We envisaged an assistantship-style elective with the aim of boosting my experience in palliative medicine and preparing me for my FY1 rotation in palliative medicine in December. This was all facilitated by the hospice HR department and undergraduate medical education team at Jersey General Hospital.

I enjoyed my elective alongside my partner who was doing her elective at the same time in obstetrics and gynaecology at Jersey General Hospital. We both arrived by ferry and were keen to get started. Note to self: take anti-sickness medication for all future boat trips. I learned the hard way…

My first week comprised of a hybrid between the hospital team and the hospice team. In the hospital, I was with one of the Staff Grade Doctors reviewing inpatient referrals. I saw a variety of cases requiring a range of support from complex symptom management to end of life care. I spent the majority of this week finding my feet but also working out the healthcare system on the island. It has been quite interesting working out what is and isn’t done on the island and the limitations to services that are provided on Jersey. Safe to say this has brought a whole new idea of postcode lottery to medical ethics discussions. For example, abortion laws are different (up to 12 weeks gestation), there are no PET scans on offer on the island, no radiotherapy department, MRI spine scans for malignant spinal cord compression are only offered when sphincter function is lost, and primary PCI is only offered in Oxford. While most services are provided on the island, there are some very challenging situations where patients are a candidate for these services however, they are not fit enough for a short flight to the UK to receive them. An ambulance ride down the road would be suitable for them if they were in the UK, however they are unfit for a flight therefore missing out on potentially life-saving treatment.

The subsequent weeks have mainly been spent on the inpatient unit in the hospice just outside of the main city of St Helier. This unit sees daily ward rounds by a Registrar with twice weekly Consultant-led ward rounds too. I spent the days working alongside the Registrar and Junior Clinical Fellow helping manage the patients that had been admitted to the hospice. Patients are admitted to the unit by the community team (staffed by Clinical Nurse Specialists) and by the hospital specialist palliative care team (staffed by a Staff Grade and Consultant). Reasons for admission include respite care, temporary symptom management, and end of life care. As you may see from the photo below the hospice and the best view in the whole of Jersey and this was my lunch view for four weeks:

My time on the inpatient hospice unit really enabled me to enhance my management plans and especially my communication skills by interacting with patients and their families. I’ve been able to build my skills during tender conversations particularly about advanced care planning, end of life care, and death. In addition to this, as a practising Christian, I have been mesmerised by the integration of spiritual care in the world of palliative medicine. I have been part of some fascinating and stimulating spiritual conversations with patients and staff members from all different spiritual care backgrounds and I’ve been able to witness the various religious practices that are carried out at the end of life. There have been many fascinating ethical and reflective conversations, amongst staff and patients and this is something that I particularly enjoy. I spent considerable time with the spiritual care lead for the hospice and on my last day I was able to spend time with the hospital chaplaincy team and welcome my dad, the Bishop of Salisbury, to the hospice to meet the team and pay the last rites to one of the patients. Just when you think you’ve seen it all, I witnessed this patient, surrounded by his family, rouse from a deep coma and recite the Lord’s prayer word-for-word one last time. I have since learned since I left the island that this patient had a very comfortable death surrounded by his family and loved ones.

Speaking of death, I can’t not mention the recent legalisation of the approval of assisted dying on the island of Jersey. This is something that may not have reached UK headlines in the news as it was approved on the same day that the general election was announced. However, this is the closest euthanasia and assisted dying has come to the British Isles. The States Assembly (the Jersey government) voted to approve route one of their assisted dying proposals. This involves legalising assisted dying for patients that have been diagnosed with the physical medical condition that meets four of the following qualifications:

  1. A terminal physical medical condition
  2. That is giving rise to or is expected to give rise to unbearable suffering
  3. That cannot be alleviated in a manner the person deemed to be tolerable and
  4. That is reasonably expected to cause the person’s death within the timeframe specified

Time frames as mentioned in point four of the qualifying criteria include six months prognosis for all terminal physical conditions or 12 months prognosis for neurodegenerative conditions such as Parkinson’s disease, Alzheimer’s disease or motor neurone disease.

These proposals were approved by the States Assembly at the end of May, the week before I went out to Jersey for my elective. As I’m sure you can imagine, this news was still very fresh and prompted some fascinating discussions and elicited the wide range of opinions that are held amongst the people of Jersey. My personal views on the assisted dying remain rather neutral. I can absolutely see arguments in favour of assisted dying but on the contrary, I can also see arguments against. Death is the one thing guaranteed to us all in our lives and it is something that is not spoken about enough. It is still a taboo in our society. Death is a natural process that happens to all living beings. Do we really want to hasten this by injecting lethal doses of medications into someone’s vein to stop their breathing and to stop their heart? However, do we really want to witness the slow, painful, emotionally tolling death endured by people with these terminal conditions? We will all know someone who has died with some form of dementia, so how can we tolerate seeing them like this? How can we sit and watch people lose their dignity at the end of their life, perhaps even many years before the end comes, and witness the unbearable suffering of motor neurone disease – a disease that targets the nerves in your body that give you the power to move and do things while sparing your brain so that you are fully aware as your body fails you until you stop breathing.

I can’t help but feel there is still a huge element of subjectivity in the proposal set out by the States Assembly. People are in unanimous agreement that patients need to be safeguarded throughout the assisted dying process. We look at examples across the world of other jurisdictions that have legalised assisted dying and are sad to learn of coercion and the unfairness involved in an assisted death. For example, Canada will offer you an assisted death because it is cheaper than a package of care to support you with the physical condition that limits your activities of daily living.

My consultant supervisor is heavily involved in the legalisation process and is a very big supporter of assisted dying. He chairs the working group for the island responsible for implementing the proposals and drafting the legislation. I was able to attend with him one of the meetings about dying with the executive group (compromising of senior lawyers, the medical director, and the chief nurse) and witness firsthand at the table the varying opinions. I was mesmerised as I sat in the corner of the room surrounded by these executives making such decisions on the lives of the present and future people of Jersey. It occurred to me that 2025 will be the year of assisted dying here in the United Kingdom and it is a topic of medical ethics that no doctor, healthcare professional, or citizen can or should avoid. It is a matter of when and not if with the assisted dying and it is paramount to ensure that the processes are safeguarded and that the vulnerable people that will accept an assisted death are kept safe and protected from coercion and manipulation. On my last day I was invited to speak to the BBC radio team about my time in Jersey and about assisted dying and this can be found on BBC sounds at 7:30 am on Sunday, the 23rd of June.

Aside from the world of palliative medicine and assisted dying, I was able to enjoy the island of Jersey for four weeks. My partner and I would spend our evenings on the beach or driving around the island to various sites. The weather was idyllic and we found the beach to be a suitable switch off for us after our busy days on placement.

 

Finally, I’d like to sum up my personal highlights from the last four weeks on Jersey. By far the best day was a boat trip to a tiny island between the coasts of Jersey and France exploring the local wildlife most notably the seals and even dolphins!

But most importantly, I have been able to pursue my love for palliative medicine and widen my opportunities to this career. I am immensely grateful to the patients and families that have allowed me to spend time with them in what is arguably the most privileged and intimate time of someone’s life. Some of the things I’ve witnessed over the last few weeks will stay with me for the rest of my career and my life, and I have no doubt that everything I’ve learned over the last month will make me a much better doctor. It is a privilege and an honour to spend time with people in the last days, hours, minutes of their lives and guide them on their natural journey from living to death. There is no better feeling than alleviating suffering.

I am immensely grateful for the funds that I have received to enable me to fully enjoy my time in Jersey and it has made me genuinely excited to start my training as a doctor and to see where my career takes.