Tuesday, 12 July 2011

Liverpool Care Pathway - A One-Way Street Of No Return

Cases abound where the potential candidate for consignment along the Pathway presents with all the appropriate signs, ticks all the right boxes, and yet rallies and improves and survives. A report which appeared in The Telegraph is a case in question:
"I have often seen this happen; patients you are convinced will follow a clear, definable illness-trajectory prove you wrong. It's this unpredictability that makes medicine so fascinating; the fact that the body has a remarkable capacity to confound expectations. Even for those with a terminal illness, there can be no certainties. It's for this reason that I despair of the Government's new treatment pattern for palliative care."
 The Liverpool Care Pathway was designed as a hospice-based care protocol for the terminally-diagnosed cancer patient; it is increasingly being used for patients who are deemed to be in the last days of life irrespective of diagnosis. Its spread is becoming global.

The LCP is ‘evidence-based’. Recognising that a patient is dying is not at all a straightforward, clear-cut matter by any means. Even so, in practice, the clinical team simply have to ‘agree’ that the patient is dying.

Two of the following ‘signs’ are looked for -
- The patient is bed bound
- The patient is semi-comatose
- The patient is only able to take sips of fluid
- The patient is no longer able to take tablets

Once enacted, the LCP replaces all other forms of documentation. This must be an inherent flaw and yet it is dismissed from consideration as such.

Once the patient has been diagnosed as ‘dying’, the LCP-trained nurses feel it makes documentation more accurate and less time consuming; in fact, it excludes all other possibilities but that of the predicted scenario.

The LCP is a legal document that every member of the LCP team works with. It has three main sections:
1. Initial assessment
2. Ongoing assessment
3. Following death.

With implementation of LCP, practice for the prescribing of ‘as required medication’ (PRN) for patients deemed ‘dying’ of non-malignant disease has changed dramatically. The LCP actually prompts the prescription of PRN medication. Prior to implementation, patients with non-malignant disease rarely had PRN medication prescribed for pain, nausea and vomiting, agitation or respiratory tract secretions (RTS). Post-implementation of the LCP, patients with non-malignant disease had PRN medication prescribed routinely!

Sadly, this prescription and administration of PRN medication for patients with non-malignant disease is perceived by clinical staff as being one of the major achievements of LCP.

Thus, these potential candidates, these intended victims - by commission of treatment started and by omission of treatment withdrawn – are set adrift across The Styx and the LCP replaces Charon to ferry them on their journey, whilst the opiates of forgetfulness and oblivion replace the waters of Lethe and they depart finally this, their earthly existence.

Dedicated nurse professionals, keen to advance their careers and add LCP to their portfolio of skills, become blinkered by the tunnel-vision concept of LCP. LCP is a bandwagon and industry which is swamping rational thinking to the contrary with the charge of denial of the basic human right of high-quality death. These dedicated nurse professionals stand in awe of its self-admiring plaudits and its blinkered logic.

From the day of conception, from the day of birth, every day is a bonus, for every day is a day along the pathway of life that brings us one day closer to our eventual, inevitable demise. It is, or should be, the task of Healthcare to provide assistance along that pathway, to provide one more day and to protect and to provide assistance and guidance to avoid the obstacles and the impediments along the way.

The LCP actually removes the individual responsibility for care. It is a pathway of death. Adherence to a LCP flowchart eliminates that accountability demanded by personal clinical decision-making. Shirking personal accountability in favour of the team approach to diagnosis that LCP provides denies the patient the option of an alternative to its predictive, ‘measurable’ outcomes.

The LCP can be discontinued it is claimed, for example if a dying patient improves, but as is shown elsewhere - see Liverpool Care Pathway - A Deterministic Pathway - the pathway is a one-way street of no return.

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