Tuesday, 18 October 2011

Liverpool Care Pathway - A Worrying Development

Overt bullying in favour of targets to the exclusion of good standards of care is reported by the Catholic Medical Association.

The Mental Capacity Act 2005 is used to supercede and over-ride the wishes of next of kin. It is in general use, along with the application of DNR orders to consign the elderly and the vulnerable on an assisted passage to the next world simply because it is an easier and cheaper option than assisting them on their passage in this!

A worrying development

The culture of death is creeping into every aspect of daily life. Of course, dying is a part of life, but the major part of life is living.

The LCP and its protocols are creeping into every compartment of care. The St. Mungo Project for the homeless in London now uses the Liverpool Care Pathway in its operation. Engaging with these lost stragglers of society, staff are encouraged to engage with clients on the subject of death and dying and identify those who need to receive end of life supportive care.

Those on the street are, generally, on a downward spiral that, if not halted or reversed, will send them to an early grave. Those engaged in their support, generally, become involved in this area of social care to lend assistance and make a difference. ‘Supportive discussion’ with the resident about their wishes for end-of-life care is not the ‘norm’ for what one might consider to be ‘supportive’ discussion.

The National End of Life Care Programme has published a ‘practical guide’ to support hostel staff in this regard.

Staff are encouraged to follow such LCP Protocols as:
Ask yourself the question “Would I be surprised if this person were to die at some stage in the near future?”

In the circumstances of the street lifestyle, living rough, that question hardly needs to be answered – or even asked!

A hostel staff member is quoted as saying:
“It can be very difficult to predict when a resident is going to die. We tend to try to find informal and supportive ways to broach the subject with each and every one of them if possible. Sometimes this is about picking up on a comment or remark made about their mortality, and using this as an entry point to further discussion.”

Mental health issues are not uncommon amongst those living on the streets. Anyone in every circumstance may make such comments or remarks about their mortality; amongst those living this street lifestyle such remarks might well be more common!

The Guide goes on: “A key challenge is knowing how and when to begin a discussion with individuals about their wishes as they near the end of life and whether they should be referred to other services.”

‘Top tips’ include: If a resident makes an advance decision to refuse life-sustaining treatment it must be in writing, signed by that person (or representative) and witnessed.

Provision of clients with a method of recording their wishes and preferences and if they choose to include an advance decision to refuse treatment is recommended. Communication of information about personal wishes and preferences (with permission) to relevant people such as the GP and out-of-hours service is advised.

In assessing social, psychological and spiritual needs and wishes of a resident, as well as their physical care needs, staff are encouraged to support, if necessary, an assessment of the individual’s ability to make decisions about their care under the provisions of the Mental Capacity Act, 2005.

“Consider how to integrate conversations into existing activities and assessments such as substance use or general key worker discussions. Recognise that greater attention and support may be required for those residents who struggle to communicate their needs because of learning difficulties, dementia or other health problems.”

The vulnerable are to be gently cajoled into making decisions which they may not fully understand or comprehend the consequences of and later regret or not wish to be enacted. In their present life situation, they may easily be persuaded to make a ‘living will’ that would, later, be detrimental to them and not compliant with their current wishes. When the time comes, they might well expect every possible effort be made to assist them to live!

End-of-Life documents include not merely attitudes to refusal of treatment but to such things as organ donation.

A new and vital source of harvested body organs?

Baroness Warnock is already quoted as saying that dementia sufferers may have a 'duty to die' because they are a burden on the NHS and their families. It is not too much a stretch of the imagination that she might extend that opinion to include these, society’s ‘stragglers’, and even suggest putting their mortal remains to some ‘good use’ in death that they were not put to in life!

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