Tuesday, 20 November 2012

Liverpool Care Pathway – A Framework For Disaster

The LCP protocols advise, also, pre-emptive prescribing, as reported and documented in these pages. Once the ship is launched across the Styx, its very momentum will bear it forth upon its journey of no return.

Commentary on the Statement supporting the Liverpool Care Pathway

The Statement supporting the Liverpool Care Pathway from the National End of Life Programme was published under multiple signatories. We have a number of serious reservations and questions about the working of the Liverpool Care Pathway.
1        The statement says, “it is not always easy to tell whether someone is very close to death”.
          The fact is that there is no scientific evidence to support the diagnosis of impending death and there are no published criteria that allow this diagnosis to be made in an evidence-based manner. This is even more true of non cancer conditions. This diagnosis is a prediction, which is at best an educated guess. Predictions have been shown to be often in serious error.
          There is no evidence that the diagnosis of impending death can be improved by using “the most senior doctor available “, and an actual misdiagnosis of impending death could result in a wrongful death.

2        “The Liverpool Care Pathway …is not a treatment”.
          This statement belies what actually happens once a patient is signed up onto the LCP. The fact that morphine, midozelam and glycopyrrolate are prescribed makes the LCP a treatment protocol.

3        “The Liverpool Care Pathway …is…a framework for good practice.”
          In the twenty-first century all good clinical practice is evidence based. Good clinical practice has always traditionally involved a close doctor-patient relationship  and the management of symptoms in the best interest of the patient, as and when they arise. The LCP is more than a framework. It is a pathway that takes the patient in the direction of the outcome presumed by the diagnosis of impending death. The pathway leads to a suspension of evidence based practice and the normal doctor-patient relationship.

4        “The Liverpool Care Pathway does not….hasten death.”
          It is self evident that stopping fluids whilst giving narcotics and sedatives hastens death. According to the National Audit 2010-2011, fluids were continued in only 16% of patients and none had fluids started.
          The median time to death on the Liverpool Care Pathway is now 29 hours. Statistics show that even patients with terminal cancer and a poor prognosis may survive months or more if not put on the Liverpool Care Pathway.
          Your statement fails to mention the relief of symptoms at all. We think this is a serious omission. The question of consent is not mentioned either.
          If as you say, the LCP does not replace “clinical judgement”, and is a “framework for good”, why is it not endorsed by 28% of senior healthcare professionals?  (National Audit 2010-2011)
          Patients should receive an individual treatment plan according to best evidence based medicine. They should not be deprived of consciousness, but receive such treatment that is aimed at relieving all their symptoms including thirst. Nothing should be done which intentionally hastens death. An individual care plan based on best evidence is preferable to a rigid pathway.


Professor P Pullicino
Prof of Neurosciences

Mr J Bogle
Chairman Catholic Union of Great Britain

Dr P Howard
Chairman Joint Medico Ethical Committee Catholic Union

Dr R Hardie
President Catholic Medical Association

Dr A Cole
Chairman Medical Ethics Alliance   

Dr M Knowles
Secretary First Do No Harm

Mrs N  McCarthy
Cathlolic Nurses Association

Ms T Lynch
Chairman Nurses Opposed to Euthanasia

Mr R Balfour
President  Doctors who Respect Humen Life

Dr J Qureshi
Founding Chairman Health and Medical Committee
Muslim Council of Britain


Letter to BMJ, "Natural Death - is a pathway needed"

The Editor BMJ

A conference of the Medical Ethics Alliance entitled “Natural Death - is a pathway needed”, on the 18th June at the Royal Society of Medicine, attracted a lot of press attention because Prof. Pullicino cast  doubt on the scientific possibility of knowing that death is imminent. One consequence of this has been the number of relatives who have contacted the MEA with highly distressing accounts of deaths on the Liverpool Care Pathway. Amongst the most alarming of which, has been the deaths of elderly people deprived of all fluids for up to fourteen days.
Insufficient attention has been given to a Scottish critique which states;
“A blanket policy of clinically assisted ( artificial ) nutrition or hydration, or no clinically assisted ( artificial ) hydration, is ethically indefensible and in the case of patients lacking capacity prohibited under the Adults with Incapacity ( Scotland ) Act 2000.1
Amongst the symptoms that the LCP lists are - pain, agitation, nausea, vomiting, and dyspnea - but not thirst, though this is one of the most distressing of all symptoms. Nor does moistening the mouth relieve it.
An open letter to NICE calling for central monitoring of complaints from relatives over the implementation of the LCP was not even acknowledged. 2 Blanket assurances that the it conforms with “gold standards” or “quality statements” will no longer suffice. It clearly does not do so.
Dr Anthony Cole
Chairman Medical Ethics Alliance

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