Liverpool Care Pathway – "We Know That We Do Not Know"

This is from Catholic Medical Quarterly -

Catholic Medical Quarterly

Catholic Medical Quarterly Volume 61(3) August 2011,  20-22

CURRENT PROBLEMS IN PALLIATIVE CARE

At the CMA Conference in London last March, Dr Philip Howard suggested that palliative care has been transformed by the secular world around us in the last few years. On the wards there has been a change in attitudes with the introduction of terminal care pathways, the most familiar of which is the Liverpool Care Pathway (LCP).

We know that prognosis is not accurate and we often get our predictions of prognosis wrong. A tool based upon prognosis is therefore dangerous as it may become a decision that a person will die. Often on such pathways triple therapy is used (with morphine, midazolam a sedative and a hyoscine which is a drug to dry secretions). This means that the patient, who may or may not be dying, is given drugs that may hasten or even cause death. This is particularly true if hydration is also withdrawn. On such a regime the patient cannot survive. Sedation towards the end of life can also take away the freedom of the individual to see their families, set their affairs in order and attend to their religious duties and spiritual preparation for death. Deprivation of consciousness removes the moral freedom of the individual. Pius XII stated that this might be used in exceptional circumstances when other means to relieve extreme suffering were not available. But to do this routinely is wrong. In Holland deep sedation is used as a substitute for euthanasia and it may also be used where for legal reasons, the legal requirements for euthanasia are absent or the process of certification is regarded as too lengthy or difficult. We now see relatives sitting around the bed in the expectation of death. Where death does not occur soon, it may be a cause of complaint.

So we must return to the view that all persons are of worth while they live. There seems little doubt that lives are being shortened. The median time of patients on the LCP is 33 hours for cancer and 30 for non-cancer diagnosis. That is a matter of concern especially if we know that we do not know the precise prognosis in non cancer diagnoses.

Increasingly, in Holland, Belgium, the Netherlands and the States of Washington Montana and Oregon, we see moves towards euthanasia and physician assisted suicide (PAS). Increasingly even in jurisdictions that do not permit euthanasia and PAS, there is a move to terminal sedation which may be used a substitute for euthanasia.

“There seems little doubt that lives are being shortened. The median time of patients on the LCP is 33 hours for cancer and 30 for non-cancer diagnosis. That is a matter of concern especially if we know that we do not know the precise prognosis in non cancer diagnoses.”