Liverpool Care Pathway - A Bureaucratic Approach To Medicine

Max Pemberton writes in The Telegraph - 

Liverpool Care Pathway: The decision to withdraw treatment from a patient is an incredibly complex one 

Finger on the pulse – His grandfather’s illness gives Max Pemberton an insight into the perils of tick-box medicine

The telephone rang. From the tone of my Gran's voice I knew immediately it was bad news. "The doctors have said they think he's going to die," she said quietly. "He's in intensive care but they think he won't last the night". I know that when doctors talk about someone dying then it there really isn't much hope.

My grandfather had been taken into hospital earlier that day with a distended abdomen. He was having difficulties breathing and had become increasingly confused. He had been admitted to a ward and arrangements had been made for him to have a scan that same day. He had been given a drink containing contrast medium that would make the image of his bowels clearer, but while he lay in the scanner he had vomited and inhaled it. He then rapidly developed pneumonia, making his breathing even worse. Blood tests had shown that the oxygen in his blood was dangerously low. He was now on intravenous antibiotics and high-flow, pressurised oxygen but was having difficulty tolerating the mask over his face, so the doctors had been forced to sedate him. Now his breathing had changed from being deep and laboured to short, shallow breaths. He was no longer struggling to get enough oxygen into his lungs.

The doctors, my Gran carefully relayed to me, warned her that this was because his body was now giving up and it was only a matter of time. My Gran didn't need to explain this to me, because I have seen it so many times before. This, I thought as I listened to her, is the typical pattern of how old people die. One thing after another, the body gets weakened, underlying problems hamper recovery, infection sets in, doctors do their best but it's futile. While personally it was devastating, medically, it was unremarkable. Any objective analysis based on medical knowledge would have assumed that my grandfather was about to die. But he didn't. He survived the night and by the morning, he had rallied. The next day, he was off the oxygen. The day after that, he was sitting out and eating some custard.

I have often seen this happen; patients you are convinced will follow a clear, definable illness-trajectory prove you wrong. It's this unpredictability that makes medicine so fascinating; the fact that the body has a remarkable capacity to confound expectations. Even for those with a terminal illness, there can be no certainties. It's for this reason that I despair of the Government's new treatment pattern for palliative care. The "Liverpool Care Pathway" involves a series of tick-box assessments, which aim to assess the likelihood of death in patients deemed to be terminally ill in hospitals, nursing and residential homes.

Under these guidelines, being rolled out across England, patients can have fluid and drugs withdrawn while on continuous sedation until they die. In a letter to this newspaper last week, experts in palliative care raised concern about this system, highlighting that this approach can mask the signs of improvement. They argued that "forecasting death" is an inexact science. I think there is a valid argument for withdrawing treatment from patients in pain and distress and making them comfortable.

As doctors, we must be aware that actively treating someone can unnecessarily prolong suffering. For this reason there is no doubt that doctors need guidance on how to manage those patients with terminal illness. But any doctor knows that the decision to withdraw treatment is an incredibly complex one, involving professionals from a wide range of disciplines including a palliative care team, and can never be as simple as filling out a sheet on a clipboard. As frustrating as it is to those in power, medicine cannot be reduced to a series of tick-boxes. Things just aren't that simple. It's why medicine is talked of as being as much an art as a science. It operates in uncertainties and requires reflexivity, adaptability and judgment that a reductionist approach can never do justice to. A bureaucratic approach to medicine is that it stops professionals from thinking. It stops them from questioning their decisions and from seeing each patient as an individual. Not only does this result in dangerous complacency, it denies the wonder of the human body. On paper, my granddad was about to die. In reality, against all the odds, he rallied and although he's still in hospital, is doing very well. He's probably reading this now. Get well soon Gramps.