Liverpool Care Pathway – Our Worst Nightmares

Are our worst nightmares about to come true?

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31 October 2012 7:40 PM

It is crunch time for clinical common sense in the care of the elderly and the seriously ill.

More elderly people cost the NHS more money. More successful and more expensive treatments cost the NHS more money. Where will this all end - with a bankrupt state or with compulsory euthanasia?

Or is there a third way? The Liberal Democrat health minister, Norman Lamb, believes there is. He wants doctors to draw up a list of patients whom they anticipate will die within one year. He calls this an 'End of life care register'. Some would call it a 'Death list'. 

The hope is that many of these patients can be helped to die comfortably and inexpensively at home.

Patients who are over the age of 65 consume over 33% of all healthcare  expenditure, much of it in the last year of life and particularly in the last two weeks of their lives if they are in hospital.

But will the Nanny State become ruled by The Dark Angel? Will we have euthanasia by degrees as care considerations gradually become government recommendations and then rules and regulations?

Already the Liverpool Care Pathway gives cause for concern. In this procedure, patients whom doctors believe are inevitably dying are deprived of potentially life-saving treatments, given heavy sedation and deprived of nutrition and fluids. Usually they die within a few days. Is that kindness or cruelty? Or is it a box to be ticked, a hospital bed to be recycled, a cost to be saved?

As a former GP with 45 years of experience, I am familiar with destitution and death.

In addition to having a full list of NHS patients, I was, at one time, the visiting GP to Rowton House in Hammersmith. The Victorian philanthropist, Lord Rowton, built a chain of hostels 'to provide decent accommodation for working men in place of the squalid lodging houses of the time'.

George Orwell, in Down & Out In Paris and London, wrote about lodging houses: ‘The best are the Rowton Houses, where the charge is a shilling, for which you get a cubicle to yourself, and the use of excellent bathrooms.’ I query the word 'excellent' for the bathrooms but there were none on the street where the occupants would otherwise be living.

The problems of caring for the elderly and indigent are not new. I rarely got to know any of the occupants of Rowton House because they tended to stay for only one night or a haphazard series of one nights. My function was simply to give them whatever help and support I could.

It did me no harm at all to see the plight of the genuinely needy. But what good would a much-vaunted 'living will', determining how they wanted their last days to be spent, be to them? The fanciful notions of cosseted politicians have little relevance at the sharp end of clinical practice.

How many people on the Liverpool Care Pathway have the potential to recover? And how would the doctors and nurses know who they are?

And how many people nowadays will not even know that doctors have put their names on an 'End of life care register'?

Whoever designed that concept is a rotten psychologist. It is inevitable that doctors will give less care, and possibly less time and human consideration, to patients whose names are on their 'death list'.

The idea is that patients on this list would be 'less likely to be subject to treatments of limited value'. I fear that 'limited value' is something that doctors might say but patients and their families might dispute.

Doctors and nurses need to use good old-fashioned clinical judgement and concepts of personal consideration. Policies and procedures are no substitute for care and compassion.

Would I myself be worried if my name were on a death list? Yes, I certainly would, whether it be through malign or benign intent. I have no wish to live in the vegetable state to which my father descended three years before his death but I also have no wish to live my final days in the wretched physical circumstances in which my mother lived hers, against my wishes, in a hospital. It would have been better for her to have died at home.

While I have my mental and physical autonomy I want to be my own guide. Without them I have no wish to be a nuisance to anyone else or to block beds and other resources that might more beneficially be used for someone else. I just hope that I shall be treated as more than a number.

I agree very much with the statement of Dr George Vaillant in his book ‘Aging Well’. He says that we should focus upon adding life to our years rather than years to our life.