Friday, 26 August 2011

Liverpool Care Pathway – What Are Its Aims And Purposes?

The Liverpool Care Pathway demands a ‘diagnosis’ of onset of death to be made and that this be followed by induction. This will involve the withdrawal of ‘futile’ intrusions accompanied by the intrusion of opiates in order to inflict a condition of “medical futility”.

An End of Life Care - Symptom Control document from NHS Milton Keynes actually takes the form of a flowchart. This particular End of Life Care flowchart document, however, blindly ensures that the pathway to death is adhered to with a deterministic strictness that defies all logic.

In referring to particular cases or interventions as "futile", the technical meaning and moral weight of this term is not always appreciated. It is important to be clear about the meaning of the concept.

To build such moral criteria into processes and procedures whereby the decision to enact them depends not upon the criteria itself but upon other criteria used as a decision-making tool to embark upon those processes and procedures is a perilous course surely tantamount to folly. When the criteria used to embark upon this particular course - or pathway – are as general and all-purpose and ‘all things to all men’ as those specified below, then that is a folly rash beyond belief.

Cases abound where the prospective candidate for consignment along the Pathway presents with all the appropriate signs, ticks all the right boxes, and yet rallies and improves and survives. In such cases, the Pathway has become commonly – and jocularly - known as the Lazarus Care Pathway. All to often, however, the pathway is followed resolutely unto death.

‘Diagnosing’ death is a difficult – precarious – enough task for a professional experienced in the care of the terminally ill, as those professionals at the Marie Curie Hospice in Liverpool will themselves attest. When doctors and nurses in hospitals and care homes across the NHS are expected to come to such decisions in enacting The Liverpool Care Pathway with the non-terminally ill, tragic outcomes are bound to occur.

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. Like a creeping plague, its spread is becoming global.

The LCP is intended to be ‘evidence-based’. Even so, recognising that a patient is dying is not at all as straightforward and 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 the patient has been diagnosed as ‘dying’, the LCP-trained nurses feel it makes documentation more accurate and less time consuming. LCP-trained nurses actually favour this and find it rewarding. The dying process becomes a controlled and predetermined procedure.

In fact, it is flawed at the outset for, once enacted, the LCP replaces all other forms of documentation.

In fact, it excludes all other possibilities but that of the predicted scenario.

In fact, it makes ‘dying’ a tidy matter, much as induction makes birthing a tidy matter, less fraught with nuisance and the unexpected. 

In fact, the LCP is no more than that - death by induction.

In fact, NHS funding is actually tied to implementation of the LCP via the CQUIN payment framework of the Department of Health. Thus, cash-strapped Business Managers will make a determined effort to inflict the LCP across the wards and ensure that its processes and procedures are adhered to without fail and without question.

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. Care after 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.

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. 

However, whilst individual palliative care of patients with non-malignant disease may warrant prescribing of PRN medication to ease suffering, that must be an individual medical decision made by the clinician to deal with the situation and cannot be a blanket approach to every situation. 

It demands the skill of the clinician, for "there is art to medicine as well as science" (Hippocratic Oath); it is what separates the good doctor from the outstanding doctor, the ordinary and mediocre from the exceptional and remarkable, for care is motivated by  empathy and compassion,  not by  process and procedure.

That is the soul and art of Medicine.

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.

Liverpool Care Pathway –Its aims and purposes

Dedicated nurse professionals, keen to advance their nursing 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 logged in newspaper and on news bulletin, blogged as anecdote on discussion board and in discussion group,  the pathway is, generally, a one-way street of no return.

The misguided and the malicious, each sees in the LCP an opportunity.

It presents the possibility to mechanise and sanitise existence into a more bland and acceptable version for the one. It removes accountability and responsibility from the equation. Everything is reduced to the fine print of practice and procedure. Even grief itself becomes a predetermined outcome.

For the other, at a personal level, an unwanted and unwelcome  ‘nuisance’ may be removed without risk of disapproval or deprecation, neatly slotted into an acceptable ‘care’ environment under the kind ministrations of the recognised LCP protocols. At another level, healthcare in general and geriatric healthcare in particular has more finite and predictable outcomes; forward-planning becomes a less worrying, less onerous task in the management of its financial consequences.

This last may be the most certain of its aims and purposes.

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