Wednesday, 14 September 2011

Liverpool Care Pathway - The Predictive Check-box

Pre-emptive prescribing

Here is James LeFanu, writing in The Telegraph:

“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.”

The correlation to draw from this statement is that it is unsafe to withdraw an intervention solely on the basis of a prognostic forecast. Prediction is always a hit and miss affair, as any astrologer will tell you!

Then, how unsafe must it be to proceed with an intervention on the same basis? And yet that is precisely what LCP recommends – ‘to Avoid Delay & Crisis’ by prescribing, even in the absence of the symptom, to pre-empt the predicted appearance of the symptom!*

*(End of Life Care - Symptom Control documents from NHS Milton Keynes)

Whilst it might be argued that an intravenous infusion is a medical intervention, ordinarily speaking, food and fluids are not an ‘intervention’ but a matter of essential life-maintenance.

The tragic logic of this statement is illustrated in the case in question which James LeFanu cites as has already been reported here.

Conversely, it is the case that our old ones, unable to feed themselves, have been left to starve. Baroness Warnock has said that elderly people suffering from dementia are “wasting people’s lives” and “wasting the resources of the National Health Service” and should be allowed to die. It could be argued that Lady Warnock’s comments, which were published in an interview with the magazine of the Church of Scotland, Life and Work, might spread a broader net to cover those not merely feeble of mind but frail of body. The old are old dodgers and old and past it in any case! There is a cruel logic to that, also.

Notwithstanding that it has been admitted that there is a lack and a scarcity of evidence with regard to the denial of hydration and feeding 
to its victims, the LCP protocol is that this shall be done in any case.

Yet, if there is a fully implemented palliative care model in place and working, working as we think it should be working, within hospice and hospital and elsewhere, what need is there for policies such as “Death with Dignity”? The one will follow, naturally upon the other. Is there a correlation or relationship between these two? Some might say, you don’t need Death with Dignity if you have a good palliative care model.

The focus should always be Life for that is what is precious. Life with dignity – until the very last breath of life!

It is always the journey that is paramount. Unless it is certain the terminus is close by anyway, it is always safer to continue to assist passage upon the journey. To keep to the well-trodden, familiar road is wiser than to follow the wayward ill-guessed track across foreign ground. That is the way of the death pathway.

The landmarks might be there and they may be familiar but to succumb to the pathfinder‘s insistence that they indicate Journey’s End is nigh, even though journey’s end is not yet in sight, that should not be a signal to hasten the journey.

If that life-focussed, quality palliative care is in place, and that care is attentive and caring, there is no need for the precipitous leap from the parapet the Pathway insists upon.

That is the mindless, tick-box mentality.

No comments:

Post a Comment