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Jeremy Hunt orders an inquiry into the Liverpool Care Pathway, and says patients and relatives must be consulted. But will the doctors pay any attention?

There is too much evidence that the LCP is being used by some doctors as euthanasia by the back door, and that they are wilfully failing to consult: the Health Secretary will be ignored

By on Friday, 9 November 2012

Palliative care specialists say doctors must be 'trained appropriately' before they adopt the Liverpool Care Pathway (Photo: PA)

Palliative care specialists say doctors must be 'trained appropriately' before they adopt the Liverpool Care Pathway (Photo: PA)

A discussion conducted on the Today programme last week, about the so-called Liverpool Care Pathway, has left me distinctly uncertain, not about whether or not the LCP is being used by some practitioners as a sort of euthanasia by the back door (since it looks to me as though it clearly is), but about how exactly we are to confront it. Some of its defenders are undoubtedly decent and compassionate people. The LCP is intended, so they say, to ease the last hours of dying patients to save them the suffering caused by invasive treatment. One defender, on the Today programme, claimed, with every appearance of sincerity, that they are simply doing what the hospice movement does: this is the introduction of real palliative care into the geriatric mainstream.

Its critics say that it is a way of hastening patients’ deaths: and the evidence really does seem to be that this is often the case. Typically, it involves most patients being sedated and then being denied nutrition and fluids by tube. There are around 450,000 deaths in Britain each year of people who are in hospital or under NHS care. About 29 per cent – 130,000 – are of patients who are on the Liverpool Care Pathway (LCP). According to Professor Patrick Pullicino, far too often elderly patients who could live longer are placed on the LCP which has now become, he says, an “assisted death pathway” rather than a “care pathway”. He cited pressure on beds and difficulty in nursing confused or difficult to manage elderly patients as factors. He has also recounted how he has personally intervened to take patients off the LCP who later went on to be successfully treated.

Now, another ingredient has been introduced into the mix: a financial incentive for hospitals to get as many elderly patients as possible on to the LCP. In some cases, it is claimed, hospitals have been set targets that between a third and two-thirds of all deaths should be on the pathway. It is also alleged that at least £30 million of taxpayers’ money has been given to hospitals over the last three years to achieve this objective. Professor Pullicino comments: “Given the fact that the diagnosis of impending death is such a subjective one, putting a financial incentive into the mix is really not a good idea and it could sway the decision-making process.”

There can be little doubt that some patients have not in fact been dying at all when they were put on the LCP and that they have then been starved and dehydrated to death as a result. We know, because of those who somehow escape, usually as a result of their relatives’ horrified intervention (that is also how we know how often old people are put on the death list without consultation). Consider the story of 82-year-old Patricia Greenwood, who was put on the Liverpool Care Pathway by doctors in Blackpool, who removed all her feeding tubes and drips. Then her family, who had not been consulted, gave her water, which effected the beginning of a remarkable recovery. Now she is planning to go on a world cruise.

The excellent Melanie Phillips recently wrote a piece questioning the LCP. She had received many letters, containing alarming accounts of what had happened to elderly relatives. “One woman, for example, wrote that her father suffered a severe stroke caused by a blood clot in his brain. ‘All fluids were removed from him and we were told he was in the final phase of his life,’ she wrote.

“‘All we were told was that there was no hope for him; it was a matter of time before he died. Eight days later, he opened his eyes and proved everyone wrong by pulling round. Two years on from this he is back at home, although in a wheelchair and with some loss of speech.’

“Another woman’s 85-year-old mother was admitted to hospital with an infected gall bladder. The following day doctors told her, to her shock, that her mother was gravely ill and had no chance of survival.

“The doctors, who included three consultants, told her that if she did not agree to the Pathway she would be adding to her mother’s distress and misery. She signed the form – only to be horrified subsequently to find her mother highly disorientated, agitated and distressed from lack of fluids and treatment.

“‘I compelled the nursing staff to restore hydration and medications, or take full responsibility for the outcome if they failed to. I also took matters into my own hands by feeding her natural yogurt, soft foods and spooning water into her – something which was to continue until she was released three days later, having been restored to full health, cracking jokes and saying goodbye to those who were unfortunately left probably to suffer the same fate.”

Is Melanie Phillips simply being sensationalist? She has been accused, she says, by more than one doctor of “deliberately sensationalising the issue in order to sell newspapers, and to that cynical end I had set out to terrify dying patients and their relatives”. There are also genuine palliative care specialists who think that some press coverage has been sensationalist, so here, in the interest of fairness and balance (always a priority for this column) is Heather Richardson, of the organisation Help the Hospices, who says that “Recent media coverage around a small number of distressing stories has been sensationalist and at times inaccurate”, and that “it risks causing unnecessary distress to people at one of the most vulnerable times in their lives and may even prevent people from receiving the care that they need.” Maybe she is thinking of apparently sensationalist headlines like “Three thousand doctors putting patients on death lists that single them out to be allowed to die”. On the other hand, read the article: it all looks believable enough to me.

It also has to be said that though Heather Richardson is herself clearly bending over backwards to be fair to the LCP, what she says at greater length doesn’t look as though she is exactly wholly convinced that the medical practitioners who operate the LCP are necessarily entirely competent or even that they are not quite often just blundering around. The give-away passages are in my italics: “Help the Hospices”, she says, “believes that the LCP has played an important role in improving the experience of people who are dying and we support the use of this tool where staff have been trained appropriately in its application.

“We believe everyone should have access to the best possible care at the end of life, whoever they are, whatever their illness and wherever they are dying. The LCP has gone a long way to help achieve this.

“But there is still a long way to go to ensure high quality care is available to all. We urgently need to build on the palliative care training which is currently available to health professionals and in particular to those who are unfamiliar with the LCP.

“It is also important that professionals in palliative care work together and with families and carers to build the evidence base for the LCP and its impact.”

There is now (or so we are told) to be a Health Department inquiry into the LCP, and the Health Secretary, Jeremy Hunt, says he plans to make it a legal right for patients and their families to be informed of end-of-life care decisions, as part of changes to the NHS Constitution. Well, that is something, I suppose. But is it enough? The medical profession has an advanced capacity to carry on doing exactly what it was doing before. Will it really pay any attention to this here today, gone tomorrow politician? I doubt it.

  • nytor

    Not merely euthanasia, but INVOLUNTARY euthanasia to boot. Nothing short of murder. Government-subsidised murder to boot. What is this highly alarming stuff about hospitals meeting targets for people going onto the LCP being given extra funding? It’s outrageous.

  • Annie

    ” . . . they are simply doing what the hospice movement does . . . another ingredient has been  introduced into the mix . . . a financial incentive for hospitals to get as many elderly patients as possible to the LCP”. 

    It would seem that a sensible way out of this mess would be to re-direct the money to the hospice services so that more people could die at home.      

  • follyscorner

    Ever since proving negligence against an NHS Trust I intend to publicise, and uphold, Professor Pullicino’s claim that when inappropriately implemented the LCP does hasten death.
    When someone commented in the Telegraph, asking Prof Pullicino to “put up, or shut up” I replied citing my experience of losing my partner after she entered the same East Kent Trust for, what should have been, an everyday biopsy.

    As opposed to accompanying me home that day the Consultant surgeon came to tell me that my Partner suffered respiratory collapse, in the recovery room, following surgery. An emergency Tracheostomy was performed and she was made stable in ICU.I next saw her consciously 4 days later on the nursing ward where she then told me, “I have been through hell”. Because she expressed a wish to seek legal action, when she returned home, I took photographs of her condition that no one has ever seen. Sadly, with no past medical history of any cancer, she died 3 weeks later of Lung cancer. She was just 63 with no terminal illnes. Not until I obtained 300 ward medical notes, that took the Trust 4 months to provide, now condemning the NHS Trust’s treatment, did I discover the surgeon had implemented the LCP without anyone’s knowledge. Together an undated DNAR notice.
    Once the enormity and gravity of the Trust’s gross negligence became apparent it was too late as once you’ve instigated the “Kafkaesque” NHS complaint procedure you are barred from engaging a solicitor. It’s now become evidently clear that the Trust, needing to avoid a post mortem from revealing the true cause of death, used the Coroner’s Officer to inform me to collect the death certificate where he deliberately lied to my post mortem status denying an investigation into a, now proven, erroneous death. The Trust and the Healthcare Commission, now CQC, finally concluded that no lung cancer was evident from the documentation provided by the Trust.A private independent report highlights missed opportunities of pulmonary embolisms for which there is no evidence of pre-surgical Heparin prophylaxis. Professor Steve Bolsin also offers his opinion that better anaesthetic drugs could have been used.I have tried, in vain, to engage a solicitor due to the Limitation period which I believe needs seriously challenging when I have the years of documented correspondence highlighting lies, deceit and dishonesty within my complaint.

  • Clare

    I personally know of  a fifty years old  who was put on the pathway within one hour of going in to our local hospice who was then ‘kidnapped’ in a comatose state by friends and is still alive one year later.
    When this was discussed with a police inspector he said it was attempted murder.
    This is clearly a matter for the police as well as health professionals.
     

  • paulpriest

    Been screaming from the rooftops about it on here for years…

    But why are Catholic Professionals telling us to “shut up about the LCP – stop criticising it!” ?

    onthesideoftheangels.blogspot.co.uk/2012/10/liverpool-care-pathway-video-updated.html … and http://onthesideoftheangels.blogspot.co.uk/2012/10/the-liverpool-care-pathway-is-backdoor.html

  • Carolynnscrim

    I am a cancer doctor and Catholic. To call the LCP euthanasia is completely wrong, and to imply that I commit a crime every day of my life I find deeply upsetting and offensive. I entered the medical profession, like most of my colleagues, to care for patients, and every day I believe i make the best decisions I can. I do not presume that i am always right – managing a patient who is dying is never easy – but I am never motivated by targets or bed needs – I am motivated by doing the best for the individual who needs help at that time. I have been asked by patients and relatives to expedite the death of a dying patient, and of course have always said that this is illegal and wrong, but I assure you it is always very difficult to watch these patients suffer and die a slow death. However, I have started countless patients on the LCP and have NEVER regretted it – it is simply a tool to help us identify early and manage the symptoms of dying and is the same as would be done without the LCP; simply more stream-lined and hopefully saves needless suffering e.g. in waiting for a doctor to prescribe a pain killer etc. Patients are never needlessly sedated and, if they are conscious, are able to eat or drink as they can, but I would strongly discourage any attempt to artificially feed a patient who is dying – having a tube put down your nose into your stomach is extremely unpleasant and completely inappropriate if someone has little time left to live. The priority should always be quality of life, not quantity.
    When it is my time to die, I hope that the LCP still exists as it is what I would want for myself. Death is inevitable; we cannot delay it forever, and when it approaches isn’t it better to treat that person with dignity and good control of symptoms, with minimal needless intervention?
    I attach a link to a blog by Dr Kate Granger – a young doctor who is termially ill. She expresses my felings much better than I could; http://drkategranger.wordpress.com/2012/11/04/end-of-life-care-through-the-eyes-of-a-doctor-and-a-patient/

  • Kevin

    But what is your response to the cases highlighted?

  • paulpriest

    Sorry Ma’am but what is your response to the 69,000 the audit revealed out of the 130,000 who were placed on the LCP with neither patient nor family consent nor without any independent second opinion. What is your opinion on prognosis based treatment rather than needs-based? i.e. 72hr prognosis permits the immediate removal of nutrition and hydration and the increase of opiate provision to toxic and continous sedation levels – all administered by LCP-untrained medical staff once a clinician or diagnostic team has made its determination?

    As this is a Catholic Newspaper Blog might I remind you that prognosis based treatment is automatically condemned by the 5th commandment, repeated papal teaching and directives have stated that nutrition and hydration are natural forms of care and NOT removable medical treatment and in 1957 Pope Pius XII in his speech to the anaesthetists declared unnecessary sedation in palliative care as barbaric, deplorable and gravely evil.

    Perhaps you are also aware of the necessity of hydration for effectively functioning analgesia? Together with the recommended provision of the anti-nausea/anti-emetic drug hyoscine which is a natural desiccating agent and accelerates dehydration and therefore muscle and organ necrosis? Or that Gomes & Trescott proved that high opiate provision for non-cancer patients actually acellerates death rather than merely sedating them?

    To deny that the LCP – even in its normative use within the provision of its ‘safeguards’ [which are ludicrously arbitrary and discretionary - terms such as 'in the patient's best interest' and 'not detrimental to the patient' - phrases which can be interpreted in multiply antagonistic and contrary ways] – is BACKDOOR EUTHANASIA!!!!

  • from nips

    As a doctor, I do not think there is anything wrong with through LCP as a tool. Everything in thiS article and all I have read is that the problem is rooted with inadequate communication between doctors, relatibes and wheee possible patients. The important role of palliative care teams in hospital has been broadly ignored and importantly people can come off the LCP.

  • CatholicDoctor

    This post is completely misinformed and serves to do nothing other than fuel the scaremongering that has occured in the media. You clearly have never had experience of using the LCP and have no concept of palliative care.
    I am a Catholic Palliative Medicine doctor.
    I take issue with the statements you have made:
    1. the LCP does not permit patients to automatically be put under continuous sedation. It recommends that patients should be prescribed sedatives to be given if they are distressed, with terminal agitation being a prominent feature in dying patients regardless of what condition they are dying from. This would involve administering medications that would ease agitation but not cause a deep continuous state of sedation. so your statement is not correct.
    2. The LCP does not permit the use of ‘toxic’ levels of opioids. It promotes the prescribing of an appropriate dose of opioid analgesia to be use if patients are dying in pain. If patients are getting toxic side effects of opioid medications then they are clearly not tolerating the current opioid precribed and an opioid switch is required. Opioids are used in the management of pain,  and have other applications such as their use for breathlessness. They are NOT for killing people. Again, your statement is not correct.
    3. Hyoscine Hydrobromide is recommened by the LCP. Its purpose is not as an antiemetic. It is used to aid in the reduction of end stage respiratory secretions, what some call a ‘death rattle’. As patients are dying they will naturally have a reduced level of consciousness and respiratory secretions can commonly gather in the upper airways. While this is felt to not be distressing to the patient, family and friends often find it very distressing to listen to this. however, we do not want to risk the chance that the patient is in some way distressed by this, and if secretions are excessive these medications can be very useful. Patients with primary lung cancer or lung metastatic disease can have particularly distressing secretions. It does not radically affect renal function and therefore will have no impact on the excretion of opioids from the patients body. This medication is commonly used in actively dying patients, providing symptomatic relief for patient and providing psychological benefit for the family and friends, your statements about muscle and organ necrosis have no basis under these circumstances and show a lack of insight as to the application of this medication.
    4. As for accelerating death with high opiate use…the LCP does not promote high opiate use in opioid naive patients. Patients who are dying and are requiring high doses of opioids are going to be those patients who have been on them longterm, during the course of their illness and such doses have been built up over time. Opioids should NEVER be used for the purpose of sedating patients. This is a misuse of such medications. Therefore if people are using them to sedate patients ofcourse it would lead to accelerated death. This is NOT how they are used in palliative care.
    5. finally… ‘backdoor euthanasia’. Lets forget the LCP just for a moment. When patients are dying they deserve care and attention. Patients under my care who are dying will be given time from all our staff, as will their family. We will work hard to keep their symptoms of pain, nausea, breathlessness, secretions, anxiety and distress undercontrol, maintaining them in a condition that they can still speak with their family and friends until their body will naturally bring them to a deeper sleep as they approach their final day or days. I do not practice euthanasia. Human life is sacred and only God can give and take it. Human life is valuable and we must treat it with respect. Now if you were to read the LCP you would see that all it does is promote this same care I offer to my patients but it asks doctors who do not do this regularly as they serve patient populations where death is not as common to stand back and ask the questions that I as a palliative doctor ask: should we subject our patient to more blood testing? have I prescribed medicines for pain/nausea/agitation/secretions incase my patient develops such symptoms? Does my patient need fluids? does my patient need artificial nutrition? (YES- the LCP asks us to consider if they are needed/if they should be continued/if they should be stopped). To continue IV fluids in a patient who is dying will only serve to increase the risk of developing respiratory secretions that I have spoken about already. A Cochrane review on the use of articial hydration in dying patients has provided NO evidence that IV fluids has any influence on survival in dying patients, you should read it.
    It is sad that a Catholic doctor commented here (Carolynnscrim) giving her experience and it was met with such a response. We need to trust in the people who are dealing with this difficult issue and who have an expert knowledge of the subject – through all the media hype the experts are being drowned out my sensationalists. The LCP is there for promote good palliative care. The examples cited in the media sound like patients who may not have been placed on it. It highlights a need for investment in palliative care provision and training of staff. It should not serve as a frenzy for scaring people about euthanasia and adding to the distress of dying patients and their families that I am seeing in my work.

  • Carolynnscrim

    I think it’s always hard to comment on individual case when only one sde has been presented – it’s hard to establish if the LCP was used inappropriately. Doctors obviously don’t always get it right and diagnosing death is difficult at times. I have certainly had patients who I thought were dying but who have then been clearly improving – the LCP has then appropriately been stopped. Any of us could list a whole load of anecdotal cases to back up our own side – I know that the LCP has helped many patients that I see, but without balaned evidence – which I have not seen, it is my strong belief that Prof Pullicino does not have reasonable grounds to make the very disturbing claims he makes.
    I would re-itterate what has been said in another post – the main problem is effective communication – I would not put a patient onto the LCP wihtout discussing it first with their family and, ideally, the patient if I can. I have never had any resistance to this up til now, but with the endless bad press about the LCP lately I fear this conversation will become harder from now on.

  • Carolynnscrim

    Euthanasia is the intentional killing of someone to ease their suffering. The LCP is at polar opposites – it is a tool to allow us to minimise the suffering of a dying patient with minial medical intervention, the judicious use of appripriate drugs in response to symptoms and good nursing and medical care. Death is happening anyway, we simply try to minimise the distress it can cause. Your comments are inflammatory and wrong.

  • Nicolas Bellord

    “However, I have started countless patients on the LCP and have NEVER regretted it ”  I find that slightly worrying.  I am sure that those who have written on this blog to support the LCP are sincere and do their best but surely there are mistakes sometimes?  But what really worries me is what might be the attitude of other doctors who have less regard for human life e.g. those who favour or actually practice abortion?  Might they not abuse the LCP?  The idea of being deprived of hydration and nutrition frightens many people and I do not think the medical profession quite realises how frightening the culture of death has made hospitals become.

  • Carolynnscrim

    What is the “culture of death”? As I’ve said, I have wrongly put people on the LCP – none of these patients have come to ham because the decisions are constantly reviewed and re-assessed. The LCP facilitates close monitoring of patients symptoms during the dying phase to ensure that symptoms are addressed, so any improvement is noted and quickly acted on. This is why I have no regrets, as I also know of many patients and families who have been supported through a peaceful death. Of course I know the issues around stopping fluids are emotive – I speak to relatives daily and have nursed relatives of my own dying from cancer – but the purpose of the LCP is to identify and ease the dying process, not to expedite death. The fear you speak of is due to some poor communication on doctors’ part, but also on incredibly biased and sometimes inaccurate reporting in the media.

  • paulpriest

     I’m sorry but you’ve completely failed to answer my concerns – and far from minimal medical intervention there is wilful removal of food and water – deemed as a clinical treatment rather than basic natural care and human decency [for what reason? other than to directly accelerate death?] and far from the mere use of analgesic level opiates – it is widely reported that opiate levels are aimed towards continuous sedation [and where non-cancer patients are involved I repeat - these levels are proven to accelerate death]

  • paulpriest

     I’m sorry but you are missing fundamental crucial aspects within your arguments…

    a] you say you have mistakenly placed people on the LCP ; but the LCP is a prognosis based deliberation – it is directly aimed towards treating a dying patient – it is not inherently reversible nor does it have the provisions for reversibility in that it is grounded in prognosis-based treatment rather than needs-based care. What provisions within the LCP itself – rather than your OWN discernment and diagnostic capabilities – assisted you in withdrawing the patient from the LCP? And I’d ask you to cite the LCP v12 itself; because I’m sorry but I simply do not believe that the LCP provides inherent safeguards to alert diagnosticians to withdraw from the pathway and reverse treatment.

    b] In what way will rapid dehydration and use of prognosis-level opiates [rather than analgesia-level] assist in determining any potential error in prognosis? How can one discern if a patient is not dying if they are at least intermittently sedated and being denied fluids?Is it not more difficult to determine that a patient is not dying of their illness while they are being poisoned by morphine, dying of thirst and mainly unconscious?

    c] You appeal to the safeguards of close monitoring:
    i] this monitoring is performed on a prognosis-based paradigm [i.e. the readings are directed towards how near the patient is from death - NOT how potentially far from death they may be]
    ii] this monitoring is performed by ordinary medical staff – NOT diagnosticians nor anyone actually trained in the LCP [how can we say this? because THERE ISN'T ANY TRAINING FOR CLINICIANS IN IMPLEMENTING THE LCP]
    So basically this isn’t monitoring for potential reversibility – this is mere record-keeping for a patient who has been determined as dying.

     

  • Stephen

    Unconscionable!  Hopefully the spotlight stays on this.

  • paulpriest

     1. Adam Brimelow’s BBC Radio4′s “The Report’ of Aug 9 revealed the widespread use of CDS in British hospitals and its euthanising potential as experienced in Dutch hospitals http://news.bbc.co.uk/1/hi/health/8184108.stm
    Rather than being a ‘prominent feature’ among the dying Dr Nigel Sykes determined that CDS is only necessary for around 0.5% of all terminally ill patients – yet it is estimated to be responsible for 18% +/- 2.5% of all hospital deaths? So for every 36 patients paced in CDS – 35 shouldn’t have been!
    Your statement is thus incorrect.

    2. Prof Anthony Cole of the Medical Ethics Alliance has stated his grave concerns over Opiate toxicity levels when aggravated by dehydration – ”
    In the MEA view there are hardly any circumstances where fluids need to
    be withdrawn, opiates become more toxic, consciousness is impaired and
    the suggested doses are too large for the frail elderly”. I have already mentioned Gomes & Trescott studies which reveal opiates are accelerating death for non-cancer patients [thus directly contradicting and disproving the stated opinion of the BCEW document on care for the dying]  The Catholic Medical Quarterly of Aug 2011 will confirm this. So I’m sorry your statement is [yet again] incorrect.

    3. You did not confirm that Hyoscine [hydro & butyl - bromides]  is indeed a desiccating agent as is glycopyrronium – and haloperidol – and Levomepromazine – and Cyclizine – and Metoclopamide – and Octreotide – every single one accelerates dehydration – A yes or no would suffice. All these drugs’ and Opiates’ effectivity and their bodily concentration levels are seriously aggravated by dehydration – yes or no?
    I was referring to the effects of long-term dehydration http://www.catholiceducation.org/articles/medical_ethics/me0074.html – something you failed to consider while attempting to misdirect by explaining Hyoscine’s usage and application – rather than the plain and simple fact that it also accelerates dehydration. Therefore your answer is neither correct nor incorrect – you shirked from answering it!
    Might I also enquire, as you’ve already mentioned lung cancer/metastatic disease, why the LCP recommends the use Midazolam for the treatment of restlessness and confusion when any pharmacopoeia will strongly warn against its usage in lung patients as it could potentially kill them!!!

    4. Could you please cite from the LCPv12 where there are any safeguards to ensure that opiate-posioning is not occurring in the patient? There is a cautionary recommendation to reduce opiate levels if renal function is seen as severely compromised – but there are no mandatory tests performed for morphine-6-gluconoride which would indicate opiate poisoning [in fact virtually all normative tests are deemed 'unnecessary' and are immediately halted once the 72hr prognosis is decreed] and myoclonic jerks can be hidden behind both delirium-incoherent spasmodic reactions and sedation. I’m sorry but you have no way of determining what levels are required for analgesia rather than following the opiate levels advised in the British National Formulary or directly from the LCP. In other words there are no provisions or safeguards for determining that opiates are not poisoning the patient…and they inevitably will be too high for some patients – but the tests and monitoring to indicate this is happening – is halted!!! So yet again your claims are incorrect.

    5. I have cited Catholic teaching on the issue – if you decide that you wish to remove the Church-decreed natural care – appealing to the equivocation that the dehydration is not accelerating death, it is rather preventing respiratory secretions – I call you out as as being economical with the truth to the point of grand larceny  – you are fully aware of the consequences and yes I have read the Cochrane 2008 and 2011 updates where although you are quite correct in your correlation of hydration with secretions – hydration also significantly reduced sedation and myoclonic jerking – and what are these symptoms of? erm Opiate posioning!!!
    Cochrane does not say what you say it does.
    The LCP most definitely does not conform to Catholic teaching in three major areas, the removal of the natural care of nutrition and hydration; gravely immoral unnecessary sedation by opiate over-use…
    …and the big one – signing the death warrant with a 72hr prognosis and actuating a prognosis-based care system rather than a [provisionally reversible] needs-based one.

    What’s more sad is that a Catholic Doctor is misdirecting, misleading and misrepresenting what is happening in the LCP – what its ‘safeguards’ actually prevent and what they permit…I don’t particularly care if you are treating your patients well…I care more that the LCP is ensuring that you MUST treat your patients well..and if it’s allowing any arbitrary, discretionary practice which will accelerate the death or even directly cause the death of the patient?

    You know what the answer is; however unpalatable…

    …ultimately we are confronting a financially-induced backdoor euthanasia genocide of our terminaly ill….

  • Carolynnscrim

    Paulpriest – I will endeavour to be as clear as i can to answer your individual points.

    a – The LCP is a tool to aid nurses and doctors to help care for the dying. It asks for regular assessment by a nurse or doctor, something that would happen off the LCP but that the caregiver is prompted to do while the patient is on the LCP. The safeguard IS the nurse or doctor seeing the patient, who are  able to observe whether the patient is improving.. The LCP is not at all one way – every practising nurse or doctor will know of patients who have been placed on the LCP but have then recovered. 

    b – I don’t understand what prognosis-based opiates means, but patients on the LCP are not denied fluids or mostly sedated – it is not a prerequisite for the LCP that the patient is off IV fluids, although we are asked to consider whether repeated attempts at cannulation for administration of fkuids is appropriate. Patients on the LCP are not sedated as a matter of course. Both of these points are fundamental to understanding why the LCP is not harmful. It is just a tool to aid the management of the dying.

    c – when assessing a patient, I am assessing the whole patient – if they are getting better we will identify that and, even if they’re on the LCP. I do take the point though that sometimes we are coloured by what we expect to see, but this is not a problem unique to the LCP.

    d -I do not believe clinicians need additional training in using the LCP since it is merely a tool to help us do what we already do – diagnose and treat the symptoms of dying. And all “ordinary medical staff” are diagnosticians – it’s what we’re trained to do.

    I realise that sometimes when medics talk about medicine to non-medics it can sound patronsing – I assure you this is not what I want to do, but just to clarify why I, as someone who believes in the sanctity of life, also believe in the LCP.

  • paulpriest

    You might not place a patient on the LCP without discussing it with those concerned first – but 69,000 of the 130,000 within the audit – were NOT consulted or gave their consent – neither the patient nor family…

    ..and with tens of millions of pounds of incentives to ensure deaths are hastened via the LCP?

    You simply cannot state there is nothing untoward in all this

    And I’m sorry but it’s not merely Professor Pullicino who is fighting for reform of the LCP…There’s Phillip Howard, Gillian Craig, Clare Walker & the Catholic Medical Association, SPUC,  Kevin Fitzpatrick of “Not Dead Yet”, Tony Cole of the Medical Ethics Alliance wrote to LCP Consultant DA Jones with his grave concerns:
    a]
    In the MEA view there are hardly any circumstances where fluids need to
    be withdrawn, opiates become more toxic, consciousness impaired and
    suggested doses are too large for the frail elderly

    b] There is no
    provision for truly independent second opinion and informed consent is
    virtually ignored [as evinced by the audit]

    c] There is no required training for anyone applying the LCP [often inexperienced staff].

    d]
    There is no certainty of determining the imminence of death –
    especially in the elderly with multiple pathologies. There is also very
    strong evidence for this given the amount of post-mortems revealing
    death by different causes to the presumed diagnosis.

    e]Difficulties will arise in this procedure from a lack of continuity in care.

    Concluding:

    What
    is virtually certain is that inexperienced , untrained staff with or
    without ill-will, will be stopping fluids and giving powerful drugs with
    lethal effect. Relatives..will be ill-informed, suspicious and
    sometimes embittered.

    The LCP should be used with great care by
    trained experienced doctors humble enough to listen to a truly
    independent second opinion. No doubt it has a place in hospices but to
    roll it out in all settings will lead to MANY premature deaths.

    The
    natural death with consciousness to the end should always be sought for
    spiritual and family reasons…The LCP does not exclude this but the
    circumstances listed above will lead to premature unconsciousness,
    intoxication and hastened deaths.

    [Finally Dr Cole leaves us with a devastating prediction]

    “Palliative Care itself could be discredited and it could play into the hands of proponents of euthanasia”

    In 2008 Adrian Treloar wrote to the BMJ

    The Liverpool care pathway (LCP) is the UK’s main clinical
    pathway of continuous deep sedation and is promoted for roll out across
    the NHS. Rietjens et al’s study highlights some serious weaknesses in its design.

    The
    eligibility criteria do not ensure that only people who are about to
    die are allowed on to the pathway. They allow people who are thought to
    be dying, are bed bound, and are unable to take tablets on to the
    pathway. In chronic diseases such as dementia, dying can take years, but
    such patients may be eligible. Reitjens et al’s paper shows that GPs
    often put patients on to such a pathway without palliative care advice. A
    pathway for general use should minimise opportunities for early or
    inappropriate use.

    Murray et al are concerned that sedation is being used as an inexpensive alternative to assessment and specialist treatment.
    The LCP recommends sedatives and opiates for all patients on an “as
    required” basis, even when they are not agitated, in pain, or
    distressed. An automatic pathway towards prescribing heavy sedatives
    incurs risks.

    Moreover, the LCP recommends setting up a
    syringe driver within four hours of a doctor’s order. This is laudable,
    if it is needed. But the pathway encourages the use of syringe drivers
    even when symptoms can be managed without them.

    The
    pathway doesn’t mention the need for food and fluids. Reitjens et al
    show that withholding artificial nutrition and hydration is the norm.
    The LCP’s omission of prompts to reconsider nutrition and hydration may
    allow serious errors in the care of dying patients. It is not
    acceptable, as Murray et al suggest, that assessing nutrition and
    hydration are not part of the pathway.

    Sedation is right
    in some situations. But as Murray et al point out, the anticipated
    outcome of continuous deep sedation is death. We must learn from
    Reitjens et al’s observation that continuous deep sedation may replace
    euthanasia. If the methods and pathways that we use for continuous deep
    sedation in the UK are flawed, then patients will die as a result of
    inappropriate use. I hope that the LCP will be reviewed and modified.

    Earlier this year  from  Dr Jacqueline Laing, Senior Law Lecturer & director of Juris wrote:

     “The Mental Capacity Act 2005 authorises doctors, in certain circumstances,
    to
    withhold all “treatment”, including food and water, from patients who
    lack capacity. Importantly, in England and Wales, legally speaking,
    food and water administered in a medical environment may be classified
    as “medical treatment”.

     In 2008 the Liverpool Care Pathway was recommended as the Department of
    Health’s End of Life Strategy and a year later 300 hospitals, 130
    hospices and 560 care homes in England had rolled out the programme.

    Medical concerns about the very possibility of diagnosing imminent death are
    familiar. Where this diagnosis is made, the combination of morphine and
    dehydration are likely to undermine a patient’s capacity. Persistent
    dehydration of even the fittest sedated patient will kill him. That is
    the
    problem with the Pathway. It reverses the burden of proof so that an
    incapacitated patient must speak on his own behalf in favour of water.
    Even
    assuming he is well enough, as Kane Gorny’s family found, his pleas may
    not be heard. The concerns of families, lawyers and healthcare
    professionals about this programme demand address.

    Healthcare costs, bed-clearing, political Malthusianism and the philosophicaldehumanisation of the vulnerable pervasive in contemporary bioethics are all likely to rationalise bureaucratised homicide.”

    I’m sorry Ma’am but the only anecdotal evidence proffered so far is by yourself  – and your personal use of diagnostic discretion as a conscientious doctor – not what the LCP would permit you to do or safeguard against your doing

  • David Lindsay

    This is what happens when you flog off the NHS to your mates and paymasters in the companies whose racket Obama is finally busting in their own country. People become refuse, to be disposed of.

    Although The Orange Book, the basis of the May 2010 coup, is behind this, the Lib Dems have in their time provided one of this country’s greatest ever pro-life MPs, right there in Liverpool.

    In fact, there have been many, many staunchly pro-life MPs from that area. But most of them have come from a different party. It is not peculiarly a Scouse thing. John Smith was totally pro-life. Gordon Brown was and is very eloquently opposed to assisted suicide.

    The present Shadow Health Secretary, Andy Burnham, is a practising Catholic who declined to back up Yvette Cooper’s condemnation of Jeremy Hunt’s expression of support for lowering the time limit on abortion to 12 weeks. Cooper’s support came instead from David Cameron and Nick Clegg.

    Save lives. Save life. Save, or restore, the National Health Service. You know what you have to do.

  • Carolynnscrim

    I repeat – fluids can be continued on the LCP. It is not necessary to stop them, although they are often because cannulation becomes difficult / impossible when someone has been on fluids or in hospital for a long time. I agree that it is widely reported that opiate levels are aimed towards continuous sedation but these reports are from the Daily Mail and are completely false.

    Repeated IV cannulation is cruel when someone is dying. Repeated NG insertion is cruel when someone is dying. When someone is dying we cannot prevent it from happening. And the LCP is not aimed at expediting death. 

    I fear i may be repeating myself….

  • paulpriest

    …and I’m sorry Ma’am but yet again you’re failing to acknowledge what the LCP [with its unsafe safeguards] can permit you to do with its ludicrous use of ambiguous terms…

    You’re being far from patronising but regrettably you’re missing the lethal potential within the LCP of being used as backdoor euthanasia by people of either ill-intent or of a more utilitarian ‘pro-euthanasia’ persuasion. You’re a good person seeing all the benefits within a tool – like the horticulturalist who would never dream of considering their garden spade’s efficacy in performing decapitations…

    This is not about how you or good clinicians utilise the LCP – this is about what it does or doesn’t do to prevent those who wish to introduce eugenics into palliative care via backdoor euthanasia…

    Don’t forget I’m not talking about abuse or misuse – I’m referring to what the weak, nondescript, arbitrary wording may permit in the LCP’s normative use…

    …and I’m sorry but people are being murdered – possibly on an unimaginable scale – this could be the stuff of nightmare!

    Certainly you would wish some necessary personal discretion and freedom to discern patient-specific palliative care – but if this has swung too far and the LCP inadvertently permits systemic production line backdoor euthanasia?

    Surely you’d concede that that would be the last thing you’d want?

    I have to ask: What if you’re wrong and everyone else is not like you and not acting like you – does the LCP prevent them from doing that which you would never consider?

  • paulpriest

     …and I fear I may be repeating myself:

    The LCP v12 – despite saying it is not against artifical hydration [hardly advocating or promoting with a double negative???]…

    [almost like it is kowtowing to the Royal College of Nurses' virtually maniacal warcry to 'remove those hydration tubes now! Put them out of their misery!']

    …it uses terms which permit removal of CNH when it is:
    a] in the patient’s best interests
    b] not detrimental to the patient.

    Now I ask you: What do those two conditionals mean?
    What do they prevent? What do they permit?

    One doesn’t need to be a deconstructuralist to realise that those terms can mean absolutely anything and the spirit of the  terms can be ignored, misused and abused accordingly – while still remaining within the stated guidelines.

    It’s not safe – you might allow hydration to continue – but what in the LCP prevents you from having an off-day and decide you wish a few more hastened expedient demises through CNH removal?

    If the LCP cannot stop you from unnecessarily accelerating the death – or even actuating the death of the patient – it needs a massive overhaul  to be made safe!!!

  • paulpriest

     Sorry David but you need to double-check the cited/implied MPs’ voting record.

  • David Lindsay

    I never cited or implied anyone’s voting record.

  • paulpriest

     You said John Smith was totally Pro-Life – he wasn’t [embryonc experimentation etc] – David Alton’s incrementalism was a disaster and actually increased the abortion limit – the deal with the devil led to the eugenic nightmare in which we now dwell…in fact f you go round the all-party pro-Life group I doubt you’d find one who conforms to a Catholic definition of being Pro-Life.

  • David Lindsay

    That depends exactly what you mean…

    In 1992, when Theresa May was trying to unseat Hilary Armstrong from a house around the corner from the one in which I lived then and am still writing this now, she claimed in her election address that she was totally opposed to abortion, in a doomed attempt to attract the support of the Vatican City State of Consett barely a decade after her party’s closure of that town’s employer. Now, though, she favours nothing more than a reduction in the time limit to 20 weeks. Funny, that.

    By contrast, the Clerk to the All-Party Parliamentary Pro-Life Group is a Labour Councillor, Ed Rennie of Ealing, whom I met at the Blue Labour conference at Nottingham earlier this year, and who works from the office of the Labour MP who chairs that Group, Jim Dobbin. One of that Group’s Secretaries is also a Labour MP, Joe Benton, while the other, Margaret Ritchie, previously led the SDLP.

  • paulpriest

     I know what and whom I mean…

  • Nicolas Bellord

    You cannot be serious in asking ‘What is the “culture of death”?’   Surely I do not have to spell out the how many unborn have died since 1967 at the hands of doctors.  Surely you are aware of the campaign to introduce euthanasia and assisted suicide?  Doctors are and will be involved in this.  As I have said I am sure that they are those like yourself who will administer the LCP in the proper way but I strongly suspect that there are others within the medical profession who will just treat it as a box-ticking exercise to get rid of those regarded as unworthy of life.  Just remember it was not Hitler who instituted the killing of the mentally handicapped – he just allowed the medical profession in Germany to do what they wanted.

  • theroadmaster

    The suspicion that the LCP has become euthanasia “by the back door” has more than rumour to support it, when one checks out the extraordinary fact that  29 % of  annual patient deaths in the UK occur within that medical treatment system and the testimony of Professor Pullicino which raises some very troubling questions about it.  An inquiry is the  least that the government can do to in order to get to the bottom of the allegations, which are bringing the LCP into disrepute.  It seems that economic targets, financial considerations and a purely utilitarian view of life,are the drivers which are behind these sinister developments.

  • paulpriest

     …and they’re attempting in the House of Lords again  in January for the TENTH time in recent years to legalise assisted suicide,,,

    The agenda is set: The people in power want it and will not cease until those who oppose it are browbeaten into submission.

    The BBC’s recent agenda via far-from-impartial documentaries, advocating/promoting news reports and even virtual propaganda dramatisations has been duly noted.

  • Nat_ons

    I doubt anyone will listen, least of medical practioners filled with the prevailing spirt of ‘humanism’ – opposed to any spirit of respect for God and his human creatures.

    There is, after all, no overwhelming controversy in Catholic moral theology/ philosophy when applying the doctrine of double effect to the care of dying – whether young or old; not even, I suspect, in offering palliative, yet harmful, care rather than imposing mere existence-extending interventions.

    So, if I understand the concerns and the practises properly, a line has been crossed in assisting the dying soul to live with human dignity until he dies .. that ethical line being the medical purpose of the ‘care’ .. and this care having then fallen into a practice of kiling by neglect (although no doubt persuing a well intentioned and superficially charitable aim, those neglectful means remain murderous in principle - death being its prime or sole object - not simply death-dealing – as an accidental effect of intervention to ease the individual while he is dying).

    The orthodox Catholic principle of care for the dying is just too slow, insufficiently scientific in method, and its ergonomic is wildly add odds with the mood music of modern medicine – Take this; Wham! Bam! there you are; It’s all done, Mam. Nonetheless, Catholic of an orthodox faith must not be so hasty as to condemn a theological truth to advance an ethical principle: for the prolongation of life, or existence, is not a divine command .. it requires a human judgement. It is, therefore, the formation of principles of care from a well informed conscience that is patently absent from this system of ‘care’; in other words, the traditional Catholic ethos is missing – not a vaguely charitable intent.

  • Aidan

    Clare
    Be good enough to state the details of this case.Please do not leave it in general terms….it is your duty to report it to the Police and to alert the relevant hospital administration
    Dan

  • Aidan

    theroadmaster
    Do please check as to Professor Pullicino’s relevant medical qualifications and clinical exprience.He is a good man exprssing views to which he is entitled as an individual who is quoted outside his expertise. His opinion is then raised to that of being the (Catholic) authority.Let us await the considered opinion of the Archbishop of Southwark
    Dan.

  • theroadmaster

    Aidan,
    Professor Pullicino has direct experience of intervening in in a case when a patient was “expected to die” within days.  The patient in question suffered from severe epileptic seizures and pneumonia, but the Professor took him off the LCP treatment and his epilepsy was soon under control.  He was discharged into the loving care of his family 4 weeks later.  Professor Pullicino in his role as senior consultant in east Kent Hospitals, is in on the ground experiencing the working of the LCP at first hand and thus would be ideally placed to give us an expert overview of it’s implications.

  • theroadmaster

    Aidan,
    Professor Pullicino has direct experience of intervening in a case when a patient was “expected to die” within days.  The patient in question suffered from severe epileptic seizures and pneumonia, but the Professor took him off the LCP treatment and his epilepsy was soon under control.  He was discharged into the loving care of his family 4 weeks later.  Professor Pullicino in his role as senior consultant in east Kent Hospitals, is on the ground experiencing the working of the LCP at first hand and thus would be ideally placed to give us an expert overview of it’s implications.

  • paulpriest

     Aidan that’s unadulterated rubbish…

  • Mr75

    Why cant a 50 year old be put on the LCP? If their condition improves they can be taken off it. 

  • Mr75

    So basically you are surprised that a framework of treatment ect intended for people who are expected to die soon actually has people who die when they are under that framework? Its a bit like saying you’d be shocked at how many people who die in car crashes where driving their car at the time. Also, all this comment on economic rubbish clearly shows you haven’t got a clue. 

  • theroadmaster

    Possibly Mr, it is you who does not have a clue in relation to the whole nature of this debate.  The LCP was supposedly setup as a palliative medical treatment system within the NHS for those suffering from grave illness and not as a convenient  means to dispose of them before their time was up.  It seems that you think that it’s chief purpose is the latter and that we should should not be shocked by the high number of patient deaths in relation to the LCP.  It also seems that you do not have a clue in relation to my reference to “economic targets”.  This was mean’t in the context of targets driven by costings which obviously impinge on NHS budgetary allocations and thus crude economic calculations.

  • Shouldhaveguessed

    my mother was put into a hospice by her doctor for few days treatment to help her quality of life, she did not have cancer she had COPD but she was not by any means dying. she never came out of Hospice alive she was put on LCP without any dicussion with any family, we where horrified and shocked when we seen her she could not move or speak to communicate with us it was horrific and we are still very angry and upset as we tried to get answers but as yet have had none from either our mothers doctor or the Hospice.

  • lifesloveslost

    My sister was put on the LCP in 2008 it was the first time we had heard of this pathway. She was 40 yrs old and had terminal cancer, a week before being put on the pathway she found out that she was 4 months pregnant as well as very seriously ill. Then late on Friday evening when I went in all her active medical treatment antibiotics, nutritional drinks, intravenous fluids were all withdrawn. Prior to this my sister  was awake, talking to us and aware of her surroundings.. She was on high doses of opiates for the pain which caused her to be tired and sleepy from time to time. We were happy that the staff were treating her symptoms and we hoped that she might live long enough to have her baby. When the pregnancy was discovered on a scan she was  offered a termination to start active cancer treatment. The pregnancy came as a great shock, the cancer had esculated in the previous weeks and had masked all normal pregnancy symptoms. Then came the horror  of looking retrospectively at the scans and medications she had been prescribed. It was a very bad time,but a child life was very precious to my sister, even though the seriousness of the situation was obvious to all.
    Then a week later we found ourselves in another horror. The Liverpool Pathway entered our lives, my sister was not asked or told about being put on the pathway. Her next of kin was brought into an office and told he was going to cause her a great deal of suffering and she would drown unless they stopped treating her and stopped her intravenous fluids. I had been with her all that day,  staff had asked me several times when her next of kin would be in. I thought it strange they had always talked to all of us, we were a close family and we were with her 24 hours a day. We had a good relationship with the staff or so we thought. When I came back after going home for an hour her venflon cannula was capped off and her intravenous fluids were down. We were very distressed an understatement, because of previous surgery on her bowel my sister was easily dehydrated, the idea of delibrately dehydrating anyone was so far removed from the NHS that I once knew. My whole family were distraught, we had a hard fight, we had a meeting with the doctors and nurses involved in her care and later that night we managed to have the fluids reattached albeit on a much reduced rate but it was something. (If the cannula had been removed before we noticed I am sure we would have had an even bigger battle). All other treatment apart from her syringe driver which contained her painkiller, anti-sickness and sedative were withdrawn. I prayed hard that the infection she had gone into hospital with would not esculate in the abscence of antibiotics, for there would be no paracetamol to control temperature on this loving and caring pathway. The first step on the way to this pathway is when you are asked if you want your relative to be resusitated. We were consulted on this as a family and we came to the agreement that to have doctors jumping on someone suffering so much pain was unbearable, and to bring her back to more suffering would be cruel. So we agreed not to have my sister resuscitated, this appears to be the green light to proceed to no active treatment, inhumane treatment and suffering.

  • http://twitter.com/Justice4Faroque Justice4DrFaroque

    Doctors should never be allowed to make patients suffer and take lives as they please.  Say ‘No’ to euthanasia. Nobody is there to monitor how drugs are used on patients. http://www.facebook.com/pages/Justice-for-Dr-Faroque-Ahmed/414271325311114

  • Pen

    I have witnessed this first hand.  It is murder and any medic who takes part in it should be prosecuted.  Medics claim the dying do not feel anything – how the hell do they know?  My advice to relatives is to monitor your loved one and if the LCP is being used challenge the medics through the courts.  Of course most people are too distressed to do this and the medics are still treated as they know best.  After Shipman maybe we should all be aware after all you only need to gain a 50% pass mark for a medical degree.

  • Ellerwood

     NHS Choices even have a page that explains what ‘assisted suicide and euthenasia’ are now!  Its like we’re being prepared for this to become legal…when we pointedout that their description fitted the LCP, the moderator removed it ,totally contrary to any guidelines whatsoever!

  • Elaine

     why do ambulance crews have such success with resus, whereas all hospital staff tell you ..’oh its awful,they’ll be disabled when they wake up  etc etc’ …its all down to poor technique…essentially, they are liars..pain or death…she was happy to undergo the pain of childbirth after all…

  • Mary

    why is it that nurses and doctors can conscientiously object to following the LCP, but  patients can’t  ? They even turn up the drip speed to knock someone unconcious so they can start the drugs…..comatose with midazolam then morphine……supposed to be s.c.but i.v.if no one is looking!

  • Peter

    And if staff have not been trained properly before using it..as is admitted above…..its a Health & Safety offence…hence Lamb’s preference for a ‘review’.
    Huge number of those involved in rolling this out are not actually doctors, but ‘Consultant Nurses’ !!! Maybe that’s why it is so flawed ????  Just nurses with a piece of paper and a title that makes them feel important…

  • watchman

    even jeremy hunts inquiry is being done by the back door,by them whom support it,  just to tell relatives and patients that they have to be told if going on the death pathway, what about the thousands that were not told or not explained they were to be starved and de hydrated and syringe induced into a coma until they obviously die it is nothing more than mass murder like all the educated doctors and professors insist it is involantary euthianasia in other words death to make money bribbary and stop bed blocking which is a fact told by doctors working in this line of work and the freedom of information act, its cruel and  evil.