Saturday, 31 March 2012

Liverpool Care Pathway – And Other End Of Life Care Pathways

Consider these sentiments….

In regard to the elderly, frail and in poor general health, either close to death or very ill -

     It is not in their best interests to 'keeping them going'.
     It was 'for the best' that the patient should have died when he or she did.
     It was better that 'she should not suffer'.
     The patient would not have wanted to 'live in a wheelchair',
     or 'be a vegetable',
     or have to stay in hospital 'with wires coming out of her',
     or 'be a burden to her family'.
     If they were animals, they would be put down.

Are these sentiments not worthy and in accordance with the humanitarian and enlightened approach expounded by the stoutest proponents of euthanasia and assisted suicide? That last comment might appear overly blunt or insensitive, but it is one that has been commonly expressed by respondents on the subject in on-line newspaper letter columns.

Certainly, these are also matters of consideration that doctors might take into account before placing a patient in their care on the LCP. As has been seen in these pages, an actual diagnosis of 'dying' need not be made; the decision to implement the LCP protocols may be reached solely on an assessment of the patient's condition and perceived quality of life. But, as has been confirmed elsewhere in these pages by Dr. Pullicino and others, that is - put plainly and simply - euthanasia.

Certainly, they reflect and are in accord with those acting in the best traditions of the Dutch practitioners of euthanasia.

The Shipman Care Pathway

These sentiments are, in fact, those expressed by Dr. Harold Shipman.

13.58Statistically, it is clear that Shipman killed mainly elderly women living alone. He also killed some men and they too were usually elderly and living alone. In general, he killed people who were in poor health. Some of the earliest killings were of patients who were terminally ill or very unwell. Many of his victims were frail and in poor general health. I have already referred to what Shipman said about the elderly to the family of Mrs Mary Coutts after her death, namely, that he did not believe in 'keeping them going'. Mrs Kathlyn Kaye, the daughter of Mrs Annie Powers, told the Inquiry that Shipman told her elderly parents that, if they were animals, he would have them put down. He may have regarded this as a joke but Mr and Mrs Powers did not. Nor did Mrs Kaye, when Shipman repeated the remark to her. I think this remark reveals something of Shipman's attitude to elderly people.
13.59Shipman seemed to think that he knew when a patient ought to die. He quite often said that it was 'for the best' that the patient should have died when he or she did. It was better that 'she should not suffer'. The patient would not have wanted to 'live in a wheelchair', or 'be a vegetable', or have to stay in hospital 'with wires coming out of her', or 'be a burden to her family'. Of course, some people make this kind of remark following a death in the belief that they are comforting the bereaved. In Shipman's case, when he had just killed a patient, it may be that he persuaded himself that what he had done was in some way justifiable. The fact that most of the early killings were of people who were either close to death or very ill lends support to that view.
13.60I think there was probably another reason why most of Shipman's early victims were terminally ill or in very poor health. For a doctor to give an overdose of opiate to a patient whose death is expected would give rise to very little risk of suspicion or detection. I think Shipman's earliest victims were those whose deaths presented the least danger of discovery. The killings of such people might also have seemed to him to be the least morally culpable. He might have persuaded himself that he was doing his patients and their relatives a favour. The psychiatrists say that these apparently logical explanations for the early killings are not inconsistent with the theory that Shipman killed in response to a need within himself. It seems to me likely that Shipman killed primarily in response to his own needs or wishes but, initially at least, selected victims whose deaths would not greatly threaten his own security and could perhaps be justified to himself in some way.
13.61Shipman continued to kill terminally ill patients over the years and also killed patients who were suffering from acute life-threatening conditions. If Shipman was called to a patient who was having a stroke or a heart attack, he would be more likely to give a lethal injection so as to ensure that the patient died there and then, rather than attempt to treat the condition and give the patient a chance of life. The killings of Mrs Sarah Williamson and Mrs Laura Linn are examples of this. These deaths would be easily explained and would give rise to a very low risk of detection. Shipman might even have justified such killings to himself on the basis that the patients' quality of life after the acute event would be poor.
13.62Shipman might also have felt justified in killing those patients who told him that they 'felt unable to go on', implying that they were ready to die. Whether such sentiments were the product of a settled wish to die or of a passing episode of unhappiness is not for me to consider. The law is clear. A doctor is not permitted to end life in response to a request and Shipman well knew that.
Perhaps, the true horror of his actions is not that he may have acted in some perverse way and “killed in response to a need within himself” as the psychiatrists would have it, but in accordance with that same ‘higher calling’ that guides the ‘mercy killers’ to advance euthanasia and assisted suicide as a valid option. After all, as a young man of just 17, he witnessed his terminally ill mother pass on in like manner. This may have affected him in a manner more profound than is realised, not to 'avenge' her death at all, but to seek a like 'merciful' end for his patients. That is surely borne out by his sentiments as are expressed above.

This from Wikipedia:
Shipman was particularly close to his mother, who died of cancer when he was 17.[5][6] Her death came in a manner similar to what later became Shipman's own modus operandi: in the later stages of her disease, she had morphine administered at home by a doctor. Shipman witnessed his mother's pain subside in light of her terminal condition, up until her death on 21 June 1963.[7]

This from the Guardian:
Why did he kill his patients?
Various theories have been put forward to explain why Shipman turned to murder. Some suggest that he was avenging the death of his mother, who died when he was 17. The more charitable view is that he injected old ladies with morphine as a way of easing the burdens on the NHS. Others suggest that he simply could not resist playing God, proving that he could take life as well as save it.

Dame Janet Smith said Shipman's weapon was his syringe 
Dame Janet Smith, who chaired the Shipman inquiry, has said that Shipman's weapon of choice was his syringe. The same is true of the LCP. Perhaps, Shipman was a man before his time. A few years later...

And Shipman would have been a fully paid up member of Dignity in Dying and practising the Shipman Care Pathway.

More from Wikipedia:
In March 1998, Dr Linda Reynolds of the Brooke Surgery in Hyde, prompted by Deborah Massey from Frank Massey and Son's funeral parlour, expressed concerns to John Pollard, the coroner for the South Manchester District, about the high death rate among Shipman's patients. In particular, she was concerned about the large number of cremation forms for elderly women that he had needed countersigned. The matter was brought to the attention of the police, who were unable to find sufficient evidence to bring charges; The Shipman Inquiry later blamed the police for assigning inexperienced officers to the case. Between 17 April 1998, when the police abandoned the investigation, and Shipman's eventual arrest, he killed three more people.[11][12] His last victim was Kathleen Grundy, a former Lady Mayor of Hyde, who was found dead at her home on 24 June 1998. Shipman was the last person to see her alive, and later signed her death certificate, recording "old age" as cause of death.
Grundy's daughter, lawyer Angela Woodruff, became concerned when solicitor Brian Burgess informed her that a will had been made, apparently by her mother. There were doubts about its authenticity. The will excluded her and her children, but left £386,000 to Shipman. Burgess told Woodruff to report it, and went to the police, who began an investigation. Grundy's body was exhumed, and when examined found to contain traces of diamorphine (heroin), often used for pain control in terminal cancer patients. Shipman was arrested on 7 September 1998, and was found to own a typewriter of the type used to make the forged will.[13]
The police then investigated other deaths Shipman had certified, and created a list of 15 specimen cases to investigate. They discovered a pattern of his administering lethal overdoses of diamorphine, signing patients' death certificates, and then forging medical records indicating they had been in poor health.[14]
Prescription For Murder, a book by journalists Brian Whittle and Jean Ritchie, reports two theories on why Shipman forged the will. One is that he wanted to be caught because his life was out of control; the other reason, that he planned to retire at fifty-five and leave the country.
Shipman's actions in the case of Kathleen Grundy are not an aberration but a real illustration of what can and could go wrong, and of which many commentators have warned. An article By Cristina Odone in The Telegraph points out that, when you are 70, a bit frail, a bit needy, someone else might decide that life would be a lot easier without you around.

Dr Raj Patel
Dr Raj Patel
Dr Raj Patel is a GP practising in Hyde (BBC News Manchester). As a young GP he occasionally stood in for Shipman as a locum and counter-signed many of his cremation forms. According to Dr Patel, there is still a "...potential for some wrongdoing by a healthcare professional or even a carer." This is echoed by Dame Janet Smith. Their concerns are in regard to death certification and should there be any more Shipmans out there. Shipman 'forged' Kathleen Grundy's death certificate to show she died of "old age" when, in fact, it was from administering diamorphine.

Question: What is the cause of death put on the death certificates of LCP patients?

More from Wikipedia:
DeathHarold Shipman committed suicide by hanging in his cell at Wakefield Prison at 06:20 on 13 January 2004, on the eve of his 58th birthday, and was pronounced dead at 08:10. A Prison Service statement indicated that Shipman had hanged himself from the window bars of his cell using bed sheets.[24] Some British tabloids expressed joy at his suicide and encouraged other serial killers to follow his example; The Sun ran a celebratory front page headline, "Ship Ship hooray!"[25]
Some of the victims' families said they felt cheated,[26] as his suicide meant they would never have the satisfaction of Shipman's confession, and answers as to why he committed his crimes. The Home Secretary David Blunkett noted that celebration was tempting, saying: "You wake up and you receive a call telling you Shipman has topped himself and you think, is it too early to open a bottle? And then you discover that everybody's very upset that he's done it."[27]
This from Mail Online -

Still wearing his ring, the loyal widow of serial killer Dr Harold Shipman

Shipman's conviction in February 2000 for killing 15 of his patients forced him to forfeit his lucrative pension.
Husband: Dr Harold Shipman, Britian's most prolific serial killer
Then he discovered his wife would get a bumper lump sum and maximum widow's pension if he died before the age of 60.

So on January 13, 2004, a day short of his 58th birthday, he duly obliged.
Less than six months later, Primrose got a £100,000 payout and an index-linked pension of £1,207 a month, at taxpayers' expense, ensuring financial security for life.

So, that's why he topped himself...

Not at all the act of a man 'ridden with guilt'.

More like the selfless act of a rational man doing the 'best' thing for his wife and family in the circumstances...

Wikipedia continues:
Despite The Sun's celebration of Shipman's suicide, his death divided national newspapers, with the Daily Mirror branding him a "cold coward" and condemning the Prison Service for allowing his suicide to happen. The Independent, on the other hand, called for the inquiry into Shipman's suicide to look more widely at the state of Britain's prisons as well as the welfare of inmates.[28] In The Guardian, an article by Sir David Ramsbotham (former Chief Inspector of Prisons) suggested that whole life sentencing be replaced by indefinite sentencing as these would at least give prisoners the hope of eventual release and reduce the risk of their committing suicide as well as making their management easier for prison officials.[28]

A 'cold coward,' cries the Daily Mirror. The woolly-headed chattering classes suggest that his sentence has denied Shipman of hope. 

Or was his action one of self-sacrifice...?

In the light of the Mail Online report, does Shipman need to be reassessed?

Shipman was a man wholly dedicated to his cause (as is Singer and his proteges). Perhaps, the only really extraordinary thing about him is that his dedication became an obsession. He was a crusader, a jihadi, for his cause!

His acts appear those of a rational man dedicated to the cause - as he saw it! - of easing suffering through the 'merciful act' of euthanasia.

The Shipman Inquiry says -

Shipman seemed to think that he knew when a patient ought to die.

And -

In general, he killed people who were in poor health. Some of the earliest killings were of patients who were terminally ill or very unwell. Many of his victims were frail and in poor general health.

Is this not also true of those social architects and advocates of the death culture mentioned in these pages...? Was Shipman the exception or has he become the rule?

The Shipman Inquiry continues -
13.64Shipman often killed patients who had a chronic condition which required a great deal of medical attention. For example, Mrs Alice Gorton, whom he killed in 1979, had terrible psoriasis. Shipman visited her very frequently to give her the supplies of the ointments and dressings she required. Mr Joseph Wilcockson, who was killed on 6th November 1989, had a painful ulcer on his leg, which was probably never going to heal. The district nurse attended regularly to dress it. Mrs Beatrice Toft had severe lung disease and used an oxygen cylinder. She had been into hospital on a number of occasions in the past and would plainly have needed a great deal of care had she lived out the terminal stage of her illness. None of these patients was close to death, however, and the suddenness of their deaths might have aroused suspicion. I suspect that Shipman selected patients such as these, who were or were about to be very demanding of his time and the resources of the practice. That he was concerned about resources is apparent from a remark he made about Mrs Edith Calverley, who had severe respiratory problems and was taking several different types of medication. After her death, Shipman remarked to the district nurse, 'That's one off my drugs bill'.
Dr. Harold Shipman acted because he was "concerned about resources" says the report.

Baroness Warnocka well-respected commentator on medical ethics, 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.

Jacques Attali, likewise, has said, "As soon as he goes beyond 60-65 years of age man lives beyond his capacity to produce, and he costs society a lot of money...euthanasia will be one of the essential instruments of our future societies."

Are these - and others - not, likewise "concerned about resources" as stated in the Inquiry report? Shipman is not the exception. He has become the rule!

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