Liverpool Care Pathway - Full Disclosure

From the British Medical Journal

End of Life Care


Gregory T Gardner, GP Principal
Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR

As a non specialist I contribute to this debate with hesitancy. Nevertheless, in spite of the laudable aims of the Liverpool Care Pathway to manage symptoms in the terminally ill and to stop all futile measures, I agree with Adrian Treloar and Mary Kiely that assessment of hydration is an important omission.

For some terminally ill patients dehydration may exacerbate other symptoms such as agitation or confusion. Correction of dehydration by the use of subcutaneous fluids may in some patients be helpful.1

The use of terminal sedation in the absence of proper assessment and correction of dehydration is bad medicine and at its worst (as in Holland) can be a substitute for euthanasia.

1 Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient? Support Care Cancer 1997;5:205-11.

Competing interests: None declared

Assessing dying

Bruno Bubna-Kasteliz, Professional Adviser

Office of Health Ombudsman, Millbank, London W1P 4QP

With 30 years' experience as a geriatrician, I always found it difficult to predict death, which is what is being sought here, in order to implement the LCP appropriately. While the LPC offers useful guidelines on the management of end-of-life symptoms, it seems to be rushing in with sedation and opiates without considering whether hydration and nutrition are also still valid treatment.

Competing interests: None declared


The role of the media in health care design

Joseph Kayalackakom Chandy (BSc, MBBS, DCH, DFFP), GP

Hugo Minney (PhD)

Shinwell Medical Practice, Horden SR8 4LE

Dear editor

The public, patients and carers need to be involved in the design of healthcare, and the involvement of national newspapers[1] in discussing the Liverpool Care Pathway (Palliative Care Guidelines) is to be welcomed.

However reasonableness doesn’t sell newspapers. Prof Millard’s letter to Daily Telegraph[2] is a case in point. Half-truths and non-sequiturs are presented as a cogent argument, and one has to wonder what point the group of authors are trying to make – is it that their unquestioned authority is under threat?

Let’s debate this pathway with full disclosure – what happened beforehand, what merits this new pathway brings, and what are the inherent risks. Let’s recognise that everyone should have an equal point of view, that doctors and nurses aren’t the ones dying or losing a loved one. But let’s above all be honest. Sincerely

REFERENCES

1 “Briefing: Fatal Decisions” by Helen Brooks; Sunday Times 6 Sept 2009 accessible at http://www.timesonline.co.uk/tol/life_and_style/health/artic le6823241.ece

2 “Dying Patients” by PH Millard, Anthony Cole, Peter Hargreaves, David Hill, Elizabeth Negus and Dowager Lady Salisbury; eletters Daily telegraph 3 Sept 2009 accessible at http://www.telegraph.co.uk/comment/letters/6133157/Dying- patients.html

Competing interests: None declared

“Let’s debate this pathway with full disclosure.”

“Half-truths and non-sequiturs are presented as a cogent argument, and one has to wonder what point the group of authors are trying to make – is it that their unquestioned authority is under threat?”

No, it is the clinicians in the hospital setting practicing the LCP who are behaving as if “their unquestioned authority is under threat” and denying full disclosure!

Laws have been set in place to permit doctors a God-given right of ownership of the patient’s decision-making capacity. Family and loved ones have actually been threatened not to intervene.

Families have had to fight, tooth and nail, to release their loved ones from the Death Pathway. This family pursued a case for three and a half years before it even being disclosed that the LCP was in place at Caterham Dene Hospital where my mother’s life was taken!

Yes, indeed, doctors and nurses aren’t the ones dying or losing a loved one. And let’s, above all, be honest! It is all too often the case that our loved ones aren’t even ‘dying’ but are only deemed to be by the Death Panel which takes the decision to place the patient on the Pathway!