Saturday, 13 October 2012

Liverpool Care Pathway – Don't Play Ball!

They want to make this a political football to kick around.They want to kid you on that's what it's all about. Don't play ball. That's not what it's all about.

Communitarianism demands a cut-off point in care provision beyond a certain age. This is not to say that it proposes a 'Logan's Run' type scenario in which, beyond a certain age, you are wafted off on a carousel into a nirvana after-life of ever-lasting death.

This is to say that, beyond a certain age, you can no longer expect that same level of care provision you had previously considered a right, i.e. rationed down to the lowest common denominator of availability.

When you reach that certain age, will you be prepared to do the right thing - and die? Will you be ready to perform this final civic duty?

Here follows an article in the opinion pages of the New York Times. The author of the article relates the story of a gentleman in a hospital 'in the east of England'.

"Anthony Gilbey’s doctors concluded that it was pointless to prolong a life that was very near the end, and that had been increasingly consumed by pain, immobility, incontinence, depression and creeping dementia. The patient and his family concurred."

The gentleman was the author's father-in-law. I have no right to question his opinions and conclusions in this very personal matter he relates. This is a very particular case relating to an inoperable and aggressive tumour, in any case.

The LCP is put in place but, in Hospice fashion, it is applied in response to a diagnosed terminal condition rather than used as a tool to make that diagnosis. I make no comment on and make no other observation on this family's tragedy.

The article betrays a simplistic logic, however; it portrays a persuasive argument, reasoned and reasonable, that, if not by intent, still belies a deadly purpose.

The circumstance the author describes, which is intimate to his own experience, is not at all typical of how the Liverpool care Pathway is generally applied. The author, if not by design or intent, still argues a cold and clinical logic that infects and becomes a political football for him to kick around.

His mindset, clearly, would have given up on Lady Jane Campbell.

Lady Jane Campbell said in a Lords debate:
“I want to guarantee that you are there supporting my continued life and its value. The last thing I want is for you to give up on me, especially when I need you most."
The application of the Liverpool Care Pathway extends into the most unlikely of settings. The LCP end-of-life protocols have even found their way into The St. Mungo Project for the homeless in London.

The article in the opinion pages of the New York Times follows -


How to Die

ONE morning last month, Anthony Gilbey awakened from anesthesia in a hospital in the east of England. At his bedside were his daughter and an attending physician.

The surgery had been unsuccessful, the doctor informed him. There was nothing more that could be done.

“So I’m dying?” the patient asked.

The doctor hesitated. “Yes,” he said.

“You’re dying, Dad,” his daughter affirmed.

“So,” the patient mused, “no more whoop-de-doo.”

“On the other side, there’ll be loads,” his daughter — my wife — promised.

The patient laughed. “Yes,” he said. He was dead six days later, a few months shy of his 80th birthday.

When they told my father-in-law the hospital had done all it could, that was not, in the strictest sense, true. There was nothing the doctors could do about the large, inoperable tumor colonizing his insides. But they could have maintained his failing kidneys by putting him on dialysis. They could have continued pumping insulin to control his diabetes. He wore a pacemaker that kept his heart beating regardless of what else was happening to him, so with aggressive treatment they could — and many hospitals would — have sustained a kind of life for a while.

But the hospital that treated him offers a protocol called the Liverpool Care Pathway for the Dying Patient, which was conceived in the 90s at a Liverpool cancer facility as a more humane alternative to the frantic end-of-life assault of desperate measures. “The Hippocratic oath just drives clinicians toward constantly treating the patient, right until the moment they die,” said Sir Thomas Hughes-Hallett, who was until recently the chief executive of the center where the protocol was designed. English doctors, he said, tell a joke about this imperative: “Why in Ireland do they put screws in coffins? To keep the doctors out.”

The Liverpool Pathway brings many of the practices of hospice care into a hospital setting, where it can reach many more patients approaching death. “It’s not about hastening death,” Sir Thomas told me. “It’s about recognizing that someone is dying, and giving them choices. Do you want an oxygen mask over your face? Or would you like to kiss your wife?”

The less obvious problem, I suspect, is that those who favor such programs in this country often frame it as a cost issue. Their starting point is the arresting fact that a quarter or more of Medicare costs are incurred in the last year of life, which suggests that we are squandering a fortune to buy a few weeks or months of a life spent hooked to machinery and consumed by fear and discomfort. That last year of life offers a tempting target if we want to contain costs and assure that Medicare and Medicaid exist for future generations.

No doubt, we have a crying need to contain health care costs. We pay more than many other developed countries for comparable or inferior health care, and the total bill consumes a growing share of our national wealth. The Affordable Care Act — Obamacare — makes a start by establishing a board to identify savings in Medicare, by emphasizing preventive care, and by financing pilot programs to pay doctors for achieving outcomes rather than performing procedures. But it is barely a start. Common sense suggests that if officials were not afraid of being “death-paneled,” we could save some money by withholding care when, rather than saving a life, it serves only to prolong misery for a little while.

But I’m beginning to think that is both questionable economics and bad politics.

For one thing, whatever your common sense tells you, there is little evidence so far that these guidelines do save money. Emanuel has studied the fairly sketchy research and concluded that, with the possible exception of hospice care for cancer patients, measures to eliminate futile care in dying patients have not proved to be significant cost-savers. That seems to be partly because the programs kick in so late, and partly because good palliative care is not free.

Even if it turns out that programs like the Liverpool Pathway save big money, promoting end-of-life care on fiscal grounds just plays into fears that the medical-industrial complex is rushing our loved ones to the morgue to save on doctors and hospital beds.

When I asked British specialists whether the Liverpool protocol cut costs, they insisted they had never asked the question — and never would.

“I don’t think we would dare,” said Sir Thomas. “There was some very nasty press here in this country this year about the Pathway, saying it was a way of killing people quickly to free up hospital beds. The moment you go into that argument, you might threaten the whole program.”

In America, nothing happens without a cost-benefit analysis. But the case for a less excruciating death can stand on a more neutral, less disturbing foundation, namely that it is simply a kinder way of death.

“There are lots of reasons to believe you could save money,” said Emanuel. “I just think we can’t do it for the reason of saving money.”

During Anthony Gilbey’s six days of dying he floated in and out of awareness on a cloud of morphine. Unfettered by tubes and unpestered by hovering medics, he reminisced and made some amends, exchanged jokes and assurances of love with his family, received Catholic rites and managed to swallow a communion host that was probably his last meal. Then he fell into a coma. He died gently, loved and knowing it, dignified and ready.

“I have fought death for so long,” he told my wife near the end. “It is such a relief to give up.”

We should all die so well.

What is referred to as 'affordable care' — Obamacare — by implication, suggests affordable to the individual. Clearly, its purpose is more conniving: it is healthcare that is affordable to the State.

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