In 1984 I was a third-year student nurse. The last secondment before my final exam was gynaecology. The wards were housed several miles away from the friends and familiar faces of the Edwardian general hospital where my training had been based. It was an unfriendly place. The staff had little time for outsiders and none for this skinny, ginger, idealistic student nurse.

In those days, before accurate scanning equipment was widely available, the diagnosis of ovarian and uterine cancer was difficult and treatments much less effective than they are now. The outlook for many was bleak. Some of the patients on the ward where I worked were a deep ochre colour from jaundice, and were so emaciated it was a miracle their skeletal legs could carry them. One woman habitually changed into a frilly yellow babydoll nightie before visiting time, which along with her heavy makeup only amplified the tragedy of her situation.

I walked along the hospital drive a different person to the one who’d arrived nine hours before

Three weeks into my stint, I came back after a couple of days off-duty to a scene which has haunted me since. A smell, worse even than gas gangrene, permeated not only the ward but the entire floor of the hospital. In a single room near the ward entrance lay the source: the woman with the yellow nightdress. Sister warned me that the woman, who was still conscious, was suffering horribly. Months before, the consultant, a kindly man in his fifties, had promised the woman he wouldn’t let this happen – but it was the weekend and, with no mobile phones, he couldn’t be reached. The junior doctor on call was powerless to help. Only the consultant in charge could prescribe what was required.

Sister asked me and an auxiliary nurse to attend to the woman. I held my breath, composed my face, concentrated on not retching and opened the door. The woman was now even thinner, just skin covering bones. Wide-eyed, gasping and swallowing, she grabbed my wrist. She tried to speak. The cancer had perforated her small bowel and chest, and faecal fluid trickled from her mouth. Her chest gurgled. She was drowning. We did our best but it was an hour at least before the consultant’s wife tracked her husband down on the golf course. Later, on the way home, I walked along the hospital drive, by chance following the hearse, a different person to the one who’d arrived nine hours before.

That evening, over gin and tonics with a school friend who was halfway through her nursing training, tears turned to anger. ‘Is this the best we can do?’ I said, lighting another Silk Cut. With the selfishness of youth we agreed that if anything happened to either of us, the other would take away the pillows in the hope of hastening pneumonia. I repeated the question.

That was almost 40 years ago, before hospice care and irrelevant to today’s discussion around assisted dying, you might think. Except that the same friend witnessed the following scenario in a hospice last year when she was visiting a young relative.

The criteria for the use of palliative sedation in terminally ill or dying patients is intractable suffering. Palliative sedation isn’t technically speaking euthanasia: the aim is to ease suffering, although the drugs used may cause respiratory depression and death to come sooner. Whether or not it is euthanasia seems, like so many polarised debates, a question of semantics, since death usually occurs within an hour and three days of commencement.

The patient was unconscious and, without question, dying. The family were present and shocked at what they saw unfolding before them; the details of which are too recent and harrowing to relate. My friend alerted the nurse in charge who came in to see the patient. She agreed that palliative sedation was required but said there was no doctor on site and nothing could be done until he got back. Defeated, the nurse hid her face in her hands. There was nothing she could within the current protocol.

The laws and guidelines which control end-of-life care are complex, taking into account ethical, legal and medical issues. Doctors, sensitive to the law and public anxiety surrounding assisted dying, are quick to reassure relatives that palliative sedation isn’t euthanasia. One of the difficulties which doctors face is that liver metabolism can vary enormously from individual to individual due to a number of factors, one of which is genetic. The same dose of morphine or oxycodone could potentially sedate and stop respiration in patient A but in patient B, who has rapid liver metabolism, barely register.

When my husband, Jeremy Clarke, was dying last May, the palliative team couldn’t control his pain even with the largest doses of oxycodone any of them had ever witnessed. The consultant had never seen anything like it and asked about his drug and alcohol intake. The former, party drugs when he could afford them, would have had little effect, I was told, but his legendary capacity for alcohol shed light on the problem.

For those suffering from degenerative life-limiting conditions and their families, assisted dying is a heartbreaking issue. For patients, doctors and those seeking to change legislation, the ethical, political, medical and legal debate seems endless. Both the BMA and the Royal College of Surgeons have taken a neutral stance.

While this debate rages on, how could we improve end-of-life care? Perhaps by separating it – within legislation and our minds – from the discussion surrounding assisted dying months before an expected death. The anxiety, sadness and depression of the final months of life could be alleviated by a more imaginative, tailored use of pharmaceuticals. I remember Brompton’s cocktail (morphine and cocaine) being used in the early 1980s. ‘Would you like your medication in a sherry, brandy or whisky base?’ Sister would ask in advance, before relaying the information to the pharmacist.

More too could be done to improve the efficacy of palliative sedation in hospices and homes. Where doctors are temporarily unavailable, prescribing could incorporate a greater level of flexibility, with guidelines for nurses to follow. Hospices are funded in the main by charitable donations. Could these funds be raised more efficiently? Could this and the government’s contribution be spent less on administration and more on care?

End-of-life care will affect us all, directly or indirectly. We shouldn’t flinch but instead do our utmost to improve it for everyone: patients, relatives, staff and the general public, to minimise avoidable suffering and anxiety. If Sister ever asks me, I’d like my medication in a large glass of Old Pulteney.<//>