Monday, 24 December 2012

Liverpool Care Pathway – The Age Of Respect

More years ago than I care to remember, I worked as a stoker at St. Annes Home for the Aged in Redhill in Surrey. It was NHS policy then - I remember reading the advisories, absolutely aghast - to treat our old ones as children, not with the dignity of those who have attained the age of respect.This was a 'kindness'.

It would appear that these ways persist.

This is The Telegraph -

Elderly are humiliated by nurses, warns report

Too many nurses are robbing elderly people of their dignity by treating them as children and stripping them of independence, a commission is to warn.
Evidence to their commission heard the devastating effect of poor care, with older people describing how their skills, self-confidence, and ability to look after themselves deteriorated in response to the way they were treated.  Photo: ALAMY

8:20AM BST 17 Jun 2012

The landmark report is expected to say that staff in hospitals and care homes are humiliating older people by feeding them to save time - rather than helping those who need it - and issuing orders about what they should wear and when they must go to bed.
Senior managers, charities and council chiefs have made a series of recommendations designed to stamp out discrimination of the elderly as well as neglect and abuse.
Evidence to their commission heard the devastating effect of poor care, with older people describing how their skills, self-confidence, and ability to look after themselves deteriorated in response to the way they were treated.
The report by Age UK, the NHS Confederation and the Local Government Association will say institutions need to do more to help older people maintain their identity, especially when they are adjusting to major changes in their circumstances, such as the loss of a partner, or the move into hospital or a care home.
In an earlier draft of the report, authors said nurses should be banned from using patronising phrase such as "How are we today, dear?" which they said belittled older people.
Recommendations due to be published on Monday are expected to say that language which denigrates older people "has no place in a caring society and should be as unacceptable as racist or sexist terms".
The report will say that expressions such as "bed blockers" to describe those waiting to be discharged from hospital should not be used because they imply that older people are a burden.
However, it will shy away from advising nurses not to call patients "dear" after the recommendation was pilloried by commentators - who said most people cared more about being treated with kindness and not being left in soiled bed sheets, than about the terms used to address them.
The commission will say staff need to give more physical and emotional support to those in their care, and to take into account the spiritual needs of elderly people, especially those reaching the end of their lives.
The report, which has been redrafted following responses from more than 200 organisations and individuals, will say hospitals and care homes could use social networking tools to store a record of an elderly person's personal preferences, to ensure they are treated like an individual.
It is expected to suggest that sites like Facebook and LinkdIn could be adapted to hold information, which would advise those caring for elderly people about the person's life, preferred habits, food and drink tastes, and any communication difficulties or triggers which could cause upset.
A paper version of such records was pioneered by the Alzheimer's Society for patients with dementia.
Other recommendations include more regular assessments of elderly people, to ensure that their pain and nutrition are managed, and to eliminate basic errors, such as forgetting to end a period when patients are "nil by mouth".
A copy of the report will be sent to every NHS hospital and care home chief executive in England.


  1. I've been thinking about the consensus statement in favour of the LCP signed by 22 public sector organisations or charities.

    I've also been considering how many professionals have either expressed opposition to the LCP and, or the current form of EoLC or have expressed deep concerns about these? To my knowledge, those who have spoken out include:

    Professor Patrick Pullicino

    Six signatories to a letter in support of Professor Pullcino's criticism of the LCP:

    Professor Peter Millard
    Dr Anthony Cole - Chairman, BMA's Medical Ethics Alliance
    Dr Rosalind Bearcroft
    Dr Gillian Craig
    Dr David Hill
    Dr Mary Knowles - Chairman, First Do No Harm

    The letter states:

    "SIR – Remarks on the Liverpool Care Pathway by Professor Patrick Pullicino at a conference of the Medical Ethics Alliance (report, June 20) gave rise to controversy.

    But he is not wrong to say that there is no scientific way of diagnosing imminent death. It is essentially a prediction. Other considerations may come into reaching such a decision, not excluding the availability of hospital resources.

    Since his talk, members of the public have given examples of inappropriate use of the Liverpool Care Pathway (used with 29 per cent of patients at the end of life). The onus of proof that the pathway is safe and effective, or even required, is upon its authors, who should furnish their evidence.

    The combination of morphine and dehydration is known to be lethal, and four-hourly reassessment is pointless if the patient is in a drug-induced coma. No one should be deprived of consciousness except for the gravest reason, and drug regimes should follow the accepted norms as laid down in national formularies.

    In the elderly, natural death is more often free of pain and distress. The only certain way of assuaging thirst in the conscious is to provide fluids orally or occasionally by another route such as subcutaneous infusion.

    The matter of informed consent is another major consideration, and it is therefore not surprising that patients are refusing the pathway in advance directives, or carrying cards refusing this form of treatment, as a measure of self-protection."

    This letter by the 'six' was, I understand, written in conjunction with the BMA's Medical Ethics Committee: does this suggest that all members of the BMA's Medical Ethics Committee:

    President: Baroness Sheila Hollins

    Chairman of the Representative Body: Dr Steve Hajioff

    Chair of Council: Dr Mark Porter

    Treasurer: Dr Andrew Dearden

    Plus members elected by the Representative Body:

    Dr J S Bamrah
    Professor Illora Finlay
    Dr Zoe Greaves
    Dr Surendra Kumar
    Professor Wendy Savage
    Dr M E Jan Wise

    Plus members elected by Council:

    Dr John Chisholm
    Dr Helena McKeown
    Dr Lewis Morrison

    Plus members appointed by Council:

    Professor Bobbie Farsides
    Claire Foster-Gilbert
    Professor Robin Gill
    Professor Ranaan Gillon
    Professor Emily Jackson
    Professor Graeme Laurie
    David Lock QC
    Professor Marilyn Strathern

    Do they share the views expressed in this letter? I know that some of them have criticised the LCP.

  2. Then we have the Muslim doctors'opposition to the LCP, represented by Dr Jafer Qureshi.

    Dr Qureshi is the founder/executive member of The Muslim Doctors’ and Dentists’ Association, co-convener of Medical Ethics Alliance and a senior member of the Muslim Council of Britain.

    Dr Qureshi stated that Muslim doctors object to sedation and withdrawal of artificial nutrition and hydration from seriously-ill patients undr the LCP. He also stated that he has received complaints from some Muslim medics that they were being placed under pressure to collude in the killings of NHS patients.

  3. Among others who have criticised or expressed concerns about the LCP and, or EoLC, are:

    Professor Mark Glaser - senior oncolgist

    Dr Philip Howard

    Dr Miriam Stoppard

    Elspeth Chowharay-Best, Hon Secretary of Alert

    Baroness Knight of Collingwood

    Archbishop of Southwark - called for review

    Dr Rita Pal

    Dioscese of Shrewsbury (The Archbishop?)

    Wesley Smith - US bioethicist

    Jacqueline Laing - barrister

    Graeme Archer - Telegraph journalist, one of many journalists expressing concerns

    Professor Carol J Gill - disabled Canadian researcher

    Dr Liz Miller

    Numerous members of the Catholic Doctors Association

    in addition:

    Terry Pratchet - has expressed concerns about involuntary euthanasia

    Alex Schadenberg, Chair EPC - has criticised abuse of LCP

    Dr Laura de Rooy, consultant neonatologist, St George’s Hospital, London (BMJ website), said: ‘It is a huge supposition to think they do not feel hunger or thirst.’

    Erick Kodish and many Dutch people oppose the Gronigen Protocal (similar to LCP).

    Bernadette Lloyd - hospice paediatric nurse criticised use of the pathway ‘The parents feel coerced' "‘I have also seen children die in terrible thirst because fluids are withdrawn from them until they die.'
    ‘I witnessed a 14 year-old boy with cancer die with his tongue stuck to the roof of his mouth when doctors refused to give him liquids by tube. His death was agonising for him, and for us nurses to watch. This is euthanasia by the backdoor.’

    Teresa Lynch, of Medical Ethics Alliance ‘There are big questions to be answered about how our sick children are dying.’

    Jamie Bogle, Barrister - experts warned that in some cases patients have been put on the pathway only to recover when their families intervened, leading to questions over how people are judged to be in their “last hours and days”.

    Carole Jones - nurse and health visitor

    Plus many hundreds of patients and family members who have suffered as a result of the application of the LCP have been highly critical of it.

    Who have I missed?

  4. The Dying Well All Party Parliamentary Group and its co-Chair, Jim Dobbin MP have called for an Inquiry into the LCP EoLC, so they must have concerns.

    Lady Jane Campbell, Baroness of Surbiton - "Don't give up on me"

    Kevin Fitzpatrick OBE, spokesman for Not Dead Yet, said: “It is very worrying that in any situation less than 100 per cent of families are being consulted...It is a shock for families to find that out."

    Doctor Roddyc
    11/10/2012 06:15 PM
    "A cricket bat is a good thing unless it is used to bludgeon somebody to death. The LCP likewise."

  5. Margaret Watt - chairwoman of the Scotland Patients Association, "The LCP can be used to bring patients' lives to a premature end."

    Michael Cubiss - amazingly happy despite having Locked in Syndrome. Communicated with a letter board "I have never wished to die." Video

    Nurse Pink - NHS abuse of elderly patients

    Rusty Lee- TV chef who saved her mother from the LCP

    Dr Michael Irwin - vice-chair of Voluntary Euthanasia Society, said: "My main concern is that diamorphine is being used without consulting patients or talking to relatives" That is involuntary euthanasia and although we know it happens, we don't know the extent - there are probably thousands of cases each year."

    Richard Marsh - heard doctors plan to switch off his life-support when RM was Locked In after a stroke. He couldn't tell them he was alive. He's now 95% recovered.