Liverpool Care Pathway – And Plausible Denial

Kafkaesque!

Thanks go to Baroness Knight of Collingtree for her noble attempt to gain rational debate in the House. Like K, her attempts to penetrate the Castle are met with frustration at every turn. She is bamboozled with flaccid, blatant denial of what is patently – and well-known to be by its victims - the truth!

Here is the Lords Hansard text followed by the embedded video from BBC Democracy Live –

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House of Lords

Wednesday, 20 June 2012.

3 pm

Prayers-read by the Lord Bishop of Exeter.

NHS: Liverpool Care Pathway

Question

3.06 pm

Asked By Baroness Knight of Collingtree

To ask Her Majesty's Government whether use of the Liverpool care pathway in NHS hospitals is consistent with the outcome of parliamentary debates and votes on euthanasia.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, the Liverpool care pathway is an internationally recognised framework to guide the delivery of high-quality care for people in their last hours or days of life. It is not a means of euthanasia and is therefore entirely consistent with the outcome of parliamentary debates and votes on the subject. The Liverpool care pathway helps to ensure that people die with dignity, respect and minimum distress.

Baroness Knight of Collingtree: My Lords, is my noble friend aware, however, that although the Liverpool care pathway is certainly not intended to be a tool for euthanasia, that is what a growing number of people now believe it to be, judging by their own experiences? Is he aware that consultants are not always informed that their patients have been put on this pathway, and neither are those patients nor their relatives invariably told? Will he look into what is happening, since the very name "pathway" indicates that they are shortly to face induced death, as indeed they do?

Earl Howe: My Lords, I recognise that some people who have been on the Liverpool care pathway have received poor care. The pathway is not of itself a guarantor of best-quality care. It has been consistently made clear in the guidance for the implementation of the Liverpool care pathway that it is in no way a replacement for clinical judgment and should not be treated as a simple tick-box exercise. Rather, it should be seen as a useful framework to guide the delivery of care in a way that complements the skill and expertise of the practitioner using it.

Lord Hunt of Kings Heath: My Lords, I refer the House to my health interests in the register. Does the noble Earl agree that the noble Baroness, Lady Knight, has done sterling work in bringing to the attention of Parliament issues to do with the appropriate feeding and nutrition of patients in hospitals, but that on this issue she is wrong? Will he confirm that the national care of the dying audit shows that in fact the vast majority of patients on the care pathway in the last 

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24 hours of their life were reported to be comfortable and receiving good clinical care, and that his department will continue to recommend the care pathway as good practice?

Earl Howe: My Lords, we will continue to do so. The Liverpool care pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good. The noble Lord was right that the recent national care of the dying audit of hospitals, run by Marie Curie in collaboration with the Royal College of Physicians, notes that in 94% of documented cases discussions explaining the use of the LCP were held with relatives or carers. That audit process gives clinicians an opportunity to feed in their views about how well, or not so well, the pathway is working in practice.

Baroness Finlay of Llandaff: My Lords, given that the Government have recognised that the Liverpool care pathway has been designed to bring the best of hospice care into other care settings, such as hospitals, nursing homes and patients' own homes, and that it is a tool-and a tool is often only as good as the person using it-will the Government ensure that Health Education England includes in its remit comprehensive education around the appropriate care of dying patients?

Earl Howe: Yes, my Lords. To ensure that it is used properly, the Liverpool care pathway emphasises the importance of staff receiving appropriate training and support in its use as well as accessing relevant end of life training and education programmes. A range of activity has been undertaken to support staff education and training and end of life care by the national end of life care programme and others. That includes the development of an extensive package of e-learning, which is free to access for health and social care staff.

Baroness Browning: Will my noble friend tell the House whether there is ongoing monitoring of patients who are sedated but not hydrated? Looking at people who are dying can take a long time. My noble friend mentioned a few hours or a few days. If you are not hydrated for days on end, inevitably death will come. What analysis is there?

Earl Howe: My Lords, one key feature of the Liverpool care pathway is regular monitoring of the patient-every four hours at a minimum, I believe. That regular monitoring process gives clinicians and nursing staff an opportunity to reassess the patient's condition to see whether they are in fact responding to treatment, whether they require a different form of treatment or whether the treatment they are being given is unduly burdensome. That regular monitoring should, I think, take care of the point my noble friend raises.

The Lord Bishop of Liverpool: My Lords, I have some contact with the Liverpool care pathway in Liverpool. Does the Minister agree that not just palliative 

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care professionals but all healthcare professionals should receive education and training in caring for dying patients? Would he also agree that in the relationship between the two, trust is paramount?

Earl Howe: My Lords, the right reverend Prelate is absolutely right. Audits that have been carried out, particularly the recent audit published in December last year, provide us with important information about the current quality of care provision. The recent audit makes a series of recommendations, including mandatory training in the care of the dying for all healthcare staff involved and a seven day, nine to five, face to face palliative care service.

Baroness Crawley: My Lords, is the Minister aware that my own dear mother spent her last days on the Liverpool care pathway? Is he further aware that our family experience was of extraordinary care and sensitivity on the part of all the healthcare professionals involved, enabling us to be with my mother peacefully at home at her death? Confusion reigns over the title. A family friend, hearing that Mum was on the Liverpool care pathway, thought that a miraculous recovery had taken place and that she was taking a leisurely stroll in one of our great northern cities.

Earl Howe: My Lords, I am pleased to hear that the noble Baroness's mother was well looked after with the benefit of the Liverpool care pathway. I take the point about the name. Indeed, the noble Baroness, Lady Finlay, can probably give us some instructive examples from Wales, where the word "pathway" has not been adopted and the process has, I believe, been refined.

Baroness Masham of Ilton: My Lords, is the noble Earl aware that some relatives and loved ones have to fight to stop their loved ones being on the Liverpool care programme? Can he think of anything worse than dying of thirst?

Earl Howe: My Lords, no one should be denied basic care at the end of life. However, that is a different question from whether artificial nutrition and hydration should be withheld. Relatives should always be consulted.

Here follows comment from the Medical Ethics Alliance -

Newsletter - 4

Saturday, 13 February 2010 20:26

The Liverpool Care Pathway

              There has been criticism of this pathway for the terminally ill in the national press. One letter, also signed by the MEA, pointed out that the pathway can be misapplied to the non dying with lethal effect and that diagnosing imminent dying is not an exact science. This was followed by many letters from members of the public which gave instances of relatives who had been put on the pathway and who survived for long periods when eventually removed, often after prolonged pleading with medical and nursing staff.

              The pathway has been updated and now includes more references to training and discussion but has still left open one of the most contentious issues, namely whether fluids should be withdrawn,  The MEA have consistently said that there are practically no circumstances when oral fluids should be stopped and we  think that fluids should be given by other means where there is a danger of opiate derivatives  and dehydration causing terminal delirium. We are also concerned about the use excessive sedation which deprives a patient of consciousness.

              The result of this controversy is that some patients will refuse the Liverpool Care Pathway in an advance directive. We know of  two organisations producing  cards or bracelets refusing it.

              The problem seems to have arisen because the pathway, developed in hospices for people with end stage cancer has been applied in other circumstances where imminent  death is not inevitable.