Wednesday, 31 August 2011

Liverpool care Pathway - A Matter Of Life And Death

 Research by Clive Seale, professor of medical sociology at Bart's and the London School of Medicine and Dentistry, suggests the use of continuous deep sedation (CDS) across the UK is far from 'uncommon'. "The only other two countries where the prevalence has been measured is in the Netherlands and Belgium," said Professor Seale.
"The surprising thing was that in the UK the prevalence of continuous deep sedation until death was very high indeed: 16.5% of all UK deaths." That is exceptional. That is twice as high as in Belgium and the Netherlands. But while rates of CDS in the Netherlands appear to be rising, the corresponding use of euthanasia has declined, indicating that the one is replacing the other.
Dr Philip Harrison, a GP now based in New Zealand, set out his concerns recently in the British Medical Journal, following the death of his father in Doncaster Royal Infirmary.

He was put under CDS without being consulted, and so had no chance to say goodbye to his family. This sort of arrogant behaviour among LCP professionals is becoming almost commonplace.

"I don't know what the legal term is but to me it was as near to a form of murder that I had come across," he said. "I have never seen that in my medical practice before. I've seen euthanasia once, but I've never seen anybody being put to death without consent." Dr Harrison said he is concerned about what could be going on across the NHS in the name of caring and terminal sedation. The truth is, no one knows.
Being put to death with consent is euthanasia; being put to death without consent is, surely, by definition, MURDER!

Typically, in the Hospice setting, in the circumstance of the diagnosed terminally ill patient, the decision to cease hydration and nutrition is taken in the context  that it is no longer ‘life-sustaining’ and to continue would be arduous and cruel because the patient is ‘actively dying’. The decision is not taken lightly but within the full moral implications of what is known as ‘futile’ treatment.

With the advent of LCP and its spread outside of the Hospice setting across the NHS and beyond, this decision is being made in more and more disregard and ignorance of its moral implications. Such lax disregard is contentious and worrying. The moral implications are actually being given little or no heed at all, the act of ceasing hydration and nutrition being but one of the processes and procedures of the end-of-life protocol itself, but one more step along the pathway.

The LCP-empowered nurses proceed with their duties oblivious of these weighty concerns. The pleas of family to reinstate and to provide hydration go unheeded. Relatives and loved ones are actually threatened if they attempt to intervene. Read more on this here -  Hospital 'starved' elderly mother.

It is a disquieting outcome that such apparent short shrift for and lack of knowledge of the medical ethics behind such terms as ‘futile’ should be so widespread. This is entirely due to the Liverpool Care Pathway being implemented outside of its original context.

This is not palliative care. This is not care in any shape or form. This is a conveyer belt deathway. When your time is deemed come by the LCP trained professionals, death will be induced. Dying will be a tidy affair, no loose ends; not fraught with the uncertain emotion of grief, but contextualised and sanitised.

He asks: When a doctor withdraws life-sustaining nutrition and fluid from a comatose or sedated patient, is this not a form of slow euthanasia?

The issue of whether or not the provision of nutrition and hydration to patients should be considered as medical treatment and, therefore, subject at some level to the discretion of doctors, has come about only through the spread of LCP.

Following court action in Ontario Canada, it was ruled that doctors are required to obtain the consent of either the patient or a substitute decision-maker (such as the patient’s family or guardian) before withdrawing life-sustaining interventions.

Italy’s parliamentary lower house voted 278-205 to pass a bill that forbids euthanasia or assisted suicide and also requires that patients not be denied life-sustaining food or fluid.
The newly enacted Italian law makes the necessary exception to feeding and hydrating in those cases when a patient is in the terminal stages of a terminal illness — this is, when the patient’s body is no longer capable of absorbing or processing food or water, making such life-sustaining efforts futile – ethically and actually - and even burdensome.

Paul Russell continues: Hwever, this is where we need to be perfectly clear on what the removal of feeding and hydration does to a patient. Other than the sort of case, described above, when a patient is in the terminal phase of a terminal illness, the removal of hydration and nutrition will either starve or dehydrate a patient to death. It can hasten the dying process in unacceptable ways by preventing the patient’s body from being able to repair and sustain itself in such a way that the underlying disease would take its natural course.
An article in the Glasgow Herald uncovered almost routine starvation in Scottish aged-care facilities and estimated that up to 50,000 patients were dying in that manner in British public hospitals each year (Glasgow Sunday Herald, July 4, 2010).

More recently, an article from The Telegraph  pointed to the fact that patients are often being sedated and then deprived of food and fluids. The article reports that, for some patients, being put on this “pathway” becomes a self-fulfilling prophecy of death because the subsequent removal of basic sustenance actually contributes to or causes early death.

This coupling of sedation to removal of food and fluids is often referred to as “terminal sedation”.

This is a world away from merely sedating someone who is experiencing unbearable pain — that is, using sedation solely as a palliative tool with a clear palliative intention to relieve someone’s pain and symptoms. As a palliative tool, this is also used to give a patient respite from pain in circumstances where their underlying illness is not yet terminal.

Sedation in these circumstances, for a day or two, can give the pain a chance to subside. This affords the sufferer great relief. Patients, according to the stage of their disease, will often return to relatively normal conditions of life and, in the early stages, may even return home and resume receiving palliative outpatient services.
Clearly, that is not what is meant by “terminal sedation”.
Clearly, neither is palliative sedation at the end of the progress of a disease — in other words, when the patient is clearly dying. This type of sedation can be managed so that the patient has intervals when they are awake so that they can communicate with family and friends gathered at their bedside.
So, if there are a wide range of circumstances when sedation is appropriate, why are not all types of sedation simply called “palliative sedation”?
What is inappropriate is not always appropriate

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