Liverpool Care Pathway - A Deterministic Pathway

An End of Life Care - Symptom Control document from NHS Milton Keynes takes the form of a flowchart. Flowcharts are used by programmers to write computer programs to tell the microprocessor, (or CPU),  what to do. However elegantly the program is written so that it is not just a basic ' number- cruncher' it is still a binary choice of ones and zeros to force a yes/no response.

Computers are logical machines; they think in one direction. In the real world, life is not as straight forward as that. Sometimes, more often than not, it is required to think in more than one direction.

People are capable of thinking in more than one direction; we think laterally, vertically, and are capable of understanding that a question is not always answerable with a simple yes or no response - there are qualifications, there are ifs and buts. Whereas people may think round this situation, machines cannot and it is precisely this situation which may cause a progamme to 'hang' or crash.

It is forcing people to adopt a mechanical yes/no attitude that is sending patients on a pathway to death that might otherwise have resulted in recovery.

The aim of this particular End of Life Care flowchart document, however, appears to be to blindly ensure that the pathway to death is adhered to with a deterministic strictness that defies even logic:

                        1. Management of Pain
             ____________|_____________
Patient is in pain                                Patient not in pain
                                                        at this time

If the patent IS in pain, it is recommended to continue with opiates.
If the Patient is NOT in pain, it is recommended to Avoid Delay & Crisis by prescribing Oral MORPHINE in any case!
             
              2. Terminal Restlessness and Agitation
                _____________|____________
        Present                                          Absent

If present, it is recommended to prescribe MIDAZOLAM.
If not present, it is recommended to prescribe MIDAZOLAM in any case!

                3. Respiratory Tract Secretions
                    __________|_________
           Present                                 Absent

If present, it is recommended to prescribe GLYCOPYRRONIUM.
If not present, it is recommended to prescribe GLYCOPYRRONIUM in any case!

                     4. Nausea and Vomiting
                     ________|________
              Present                        Absent

If present, it is recommended to prescribe CYCLIZINE.
If not present, it is recommended to prescribe CYCLIZINE in any case!

                             5. Dyspnoea
                    ________|________
             Present                        Absent

If present, it is recommended to continue with opiates or begin prescribing them.
If not present, it is recommended to Avoid Delay & Crisis by prescribing morphine in any case!

A YES/NO flowchart choice response is presented when, in fact, there is no choice and the end result is the same.


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