Thursday, 10 January 2013

Liverpool Care Pathway - And The Certainty Of Uncertainty

Peter Saunders recently posted on Christian Medical Comment setting out nine points for the government to consider in its review of the Liverpool Care Pathway.

Here follow eight points and a summary statement on the Liverpool Care pathway from John Smeaton -

There [is] little recognition that experts who have spoken out about the LCP have said that the problems with the LCP are fundamental. It is those fundamental problems, not bad practice of the LCP, which are to blame for the scandals which the media has brought to light.

Here are some of the fundamental problems and systemic issues with the LCP which experts have highlighted:
  • The central requirement for starting the LCP is that the patient is in the last hours or days of life, yet doctors' predictions that someone is going to die imminently are almost certainly frequently wrong. The pathway leads to a suspension of evidence-based practice and the normal doctor-patient relationship.
  • The LCP has a machine-like efficiency in producing death. As the LCP entails progressively increasing doses of a sedative and a narcotic, improvement in the underlying illness may be impossible to detect.
  • Any chance of recovery may be jeopardized by high doses of narcotics recommended by the LCP, which may also be lethal.
  • The moral obligation to supply fluid to the dying who may experience thirst - part of basic care - is being flouted under the LCP.
  • Doctors are being pressurized to participate in the LCP even when they feel very uncomfortable about it, being told that the LCP is national policy. Some doctors are losing control of the clinical care of their own patients.
  • The practice of terminal sedation, involving continuous sedation and cessation of fluids, cannot be justified under the principle of double effect. The prognosis of imminent death may well be a self-fulfilling prophecy. The LCP's combination of narcotics and dehydration is ultimately lethal. In many cases it appears that there is a deliberate intention of hastening death
  • The LCP is usually applied without the knowledge or consent of the patient. The lack of assessment of mental capacity of patients and the lawful obtaining of informed consent are serious concerns.
  • There is little point in reassessing at four hourly intervals if the patient is in a state of drug-induced unconsciousness. No one should be deprived of consciousness except for the gravest reasons.
Today a parliamentary answer on the LCP from Earl Howe, a health minister, was published. Among other things he said:
"The LCP is not a treatment but a framework for managing treatments. Consent is therefore not required for the LCP itself, but normal consent rules apply to treatments while someone is on the LCP."
However, as is clear from the evidence coming to light - the testimony of over 400 people and rising - patients and/or their loved ones are frequently not informed that the patient's treatments are being managed under the LCP. It is the LCP's modus operandi regarding prognosis, medication and hydration which is causing the widely-reported high number of premature deaths. It is misleading to claim that the LCP is not a treatment and just a framework when in fact it is a treatment protocol.

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