Friday, 9 September 2011

Liverpool Care pathway: Doctors In Blinkers


BMP (Best Management Practice) is considered by some to describe the process of developing and following a standard way of doing things that multiple organizations can adapt and use locally. With proper processes, checks and testing, it is thought that a desired outcome can be delivered more effectively with fewer problems and unforeseen complications. In addition, a "best" practice can evolve to become better as improvements are discovered.

By such means has the Liverpool Care Pathway (LCP) proliferated.

Here is James LeFanu on this subject, writing in The Telegraph:

Clinging to a Pathway can lead care off track

There is much to be said, when it comes to promoting good medical practice, for “doing things by the book” — instituting standard routines with a clear rationale. This particularly applies in hi-tech situations such as the intensive care unit where, for example, the regular monitoring of vital signs allows for problems to be promptly identified.

The same principle now applies to the care of the terminally ill in the form of the Liverpool Care Pathway, which ensures that feeding, sedation and pain control are dealt with in a consistent and effective manner. This has, argues Professor John Ellershaw, director of the Marie Curie Palliative Care Institute in Liverpool, “led to demonstrable improvements in care in the last days” while discouraging inappropriate medical interventions.

It might seem churlish to criticise, but the distressing account by a reader of her late brother’s experience with the Pathway illustrates the potential for this soundly based protocol to merge into a box-ticking ritual. Her brother, when still in his early sixties, was found to have a tumour of the pancreas too advanced to permit anything other than a palliative operation. He recovered well for a few weeks, before going into a final decline, at which point the decision was made to restrict fluids and food. “He became more and more distressed,” she writes, “would plead for water and when refused would fight to get up and get it for himself.”

The nurse in charge of his care apparently insisted he was not being “denied” fluids, just not being given them. This went on for a grisly few weeks until his inevitable demise, without his medical care being monitored or reviewed by a palliative care team at any time.

It is clear enough what went wrong here. It started with a faulty judgment about her brother’s prognosis, followed by an obstinate refusal to deviate from the Pathway once initiated. Beyond that, it would seem the issue of hydration merits further attention. It is one thing to discontinue an intravenous infusion when the end is imminent; quite another to restrict fluids based on a prediction of how much longer a patient has to live.

No comments:

Post a Comment