Thursday 22 November 2012

Liverpool Care Pathway – The Missing Link

From the BMJ archives -

"... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."


Continuous deep sedation in patients nearing death


Palliative care and sedation: the Liverpool Care Pathway   

19 May 2008

I have followed the online debate about continuous deep sedation in patients nearing death with growing concern, for the debate is in danger of being sidelined by semantics. Dr Adrian Treloar need not have apologised for using the term ‘continuous deep sedation’ in relation to the Liverpool Care Pathway (LCP) (1). It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills.
Palliative carers try to reassure the worried public by saying that some patients (in fact a mere 3-5% according to Ellershaw) improve when placed on the LCP (2). There are always exceptions that prove the rule! Patients with heart failure that has been made worse by fluid overload may improve when drips are stopped. Patients who have been made worse by their medication may improve when the offending drugs are stopped. The lucky few will recover when placed on the LCP- (providing that someone notices their improvement and takes them off the pathway in time), but the great majority will die.
Therefore before putting anyone on the LCP doctors should be confident of their clinical diagnosis. They should have considered and tried to treat any reversible factors and they should be capable of accurately predicting close proximity to inevitable death. But these are counsels of perfection and doctors are fallible. A recent study has shown that health care professionals in a hospice setting are wrong 50% of the time when predicting patient survival (3). Such is the pressure to roll out the LCP nationwide that many patients, especially the frail elderly, are at risk of having their lives shortened prematurely. That may suit economists and politicians with eyes on the balance sheet rather than the patient, and it may suit those who resent having elderly bed-blockers on their wards, but it is not good medicine. Poor end of life care undermines the trust between doctors and their patients.
It is surely time to put the LCP on hold until all the concerns that have been raised online at http://www.bmj.com and elsewhere (4,5) have been carefully considered. It is time for those who advocate sedation without hydration at the end of life to examine their motives. It is time for the medical profession to take collective responsibility for end of life care, for this topic is far too important to be left to palliative carers and the Department of Health. We must not allow ourselves to be driven by individuals or organisations with vested interests or by quasi- governmental committees meeting behind closed doors. It is time to say enough is enough!
Yours truly,
Dr Gillian M Craig. 
E mail: craig.gm@clara.co.uk.
References and notes.
1. Adrian J. Treloar . LCP concerns:-clarifications and an apology. (6 May 2008)http://www.bmj.com/cgi/eletters/336/7648/781. accessed 14.05.08.
2. John E. Ellershaw . Re: Continuous deep sedation in the UK-Dutch research reflects problems with the Liverpool Care Pathway. (4 May 2008) http:/www as above.
3. Feargal Twomey, O’Leary N, O’Brien T. Prediction of patient survival by healthcare professionals in a specialist palliative care inpatient unit: a prospective study. American Journal of Hospice Care, Vol 25 No 2. April/May 2008, p139-145. DOI:10.1177/1049909107312594
4. Gillian Craig. Palliative care in overdrive: patients in danger. American Journal of Hospice and Palliative Care, Volume 25 No 2, April/May 2008, p 155-160. DOI:10.1177/1049909107312596
5. For a decade of debate about sedation without hydration see Craig GM (Ed) “No Water-No Life: Hydration in the Dying”. Fairway Folio 2005. ISBN 0 9545445 3 6. Available from Medical Ethics Books PO Box 341 Northampton NN3 2WZ. E mailbooks341@clara.co.uk.
Competing interests: None declared
Competing interests: None declared

1 comment:

  1. Well said, Dr Gillian Craig, thank you so much for speaking out. I hugely admire you for this.

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