Thursday, 10 January 2013

Liverpool Care Pathway - A Compulsory Medical (Non-)Intervention

This is from A Blog of Letters -

A Blog of Letters

JANUARY 7, 2013
RE: Terminal patient care and the place of familial consent in the NHS

Dear Mr Hunt

I am writing to request that you organise, in the next twelve months, some kind of independent, impartial, and above all, thorough investigation into a serious situation that has been reported on in the national press over the past few months. Namely the question of whether or not certain policies that have applied in several corners of the National Health Service have in fact resulted in a situation where doctors may be prescribing policies that have significant impact on possibly terminal patients’ condition, without familial consent.

The specific cases here referenced are those of the Liverpool Care Pathway for the Dying Patient (LCP), which has been a press issue for several years, and the case of May and David James, in January of this year.

It is of immense concern, in the general instance, that the Royal College of Physicians discovered that LCP policies have been implemented in up to half of cases without informing the family of the patient in question. It is also worrisome that there have been some reports of patients death’s being hastened by the LCP, particularly since their conditions may have been improving. This, coupled with unclear positions on artificial hydration, and a number of other extremely harrowing factors, such as the lack of documentation surrounding certain patients being placed on the program, is naturally very worrying to the general public.

In the specific instance, we see the case of David James, who recently passed away when his heart stopped and doctors made no attempt of any kind to resuscitate him, despite the family’s explicit request that they did so. This decision is of immense concern, because it essentially amounts to the state (the NHS in this case) acting on their own estimation of the quality of life that Mr James would experience, and then basing their resultant actions on that decision. I am quite sure you will agree, that the notion of the state being able to dictate at what point an individual’s quality of life is low enough to warrant withdrawal of medical treatment, is of grave concern.

It is true that a similar case has arisen in recent times that may give doctors more confidence to make such decisions overriding familial concerns, however I should like to point out the flaws in that defence. The case in question being of Neon Roberts, and the decision by the courts to force that child’s mother to accept the medical radiology treatment for her son’s brain tumour that the doctor recommended. While this may seem to be a case setting a precedent of medical authorities being permitted to overrule family wishes, I feel the need to point out two distinct problems with this argument.

First, in the case of Neon Roberts, the family was disunited. The father wished for the treatment to go ahead, while the mother refused. In a situation without a united family, it is of course apt that an informed medical authority act as a final third-party arbiter, so to speak. In the case of Mr James however, there was no family disunity to speak of. The family was quite united in the desire Mr James to be treated in every available manner. Therefore, the intervention of the doctors is entirely inappropriate.

Second, in the case of Neon Roberts, the medical professionals were encouraging an initiation of treatment, rather than a withdrawal. The doctors were confronted by a family member who wished them to hold back from undertaking their primary function. I am sure you can agree that it is entirely appropriate for doctors to have legal support in place to allow them to do their jobs, but when it comes to withdrawal of their services, that is a different matter entirely.

It is important to note that this is not a letter protesting government policies that may be seen to be encouraging euthanasia. That is an entirely different, and far more general matter to the one being discussed here. Rather, this is a letter expressing concern at the ability of medical professionals to act in a manner that may shorten a given patient’s life, without the consent, or even the knowledge, of that patient’s family. While there are many and varied opinions on the question of euthanasia, an area of wide agreement is that any policy that allows treatment to be withdrawn should, in the first instance, be based on the wishes of the patient and the family. I find it hard to believe that you would not consider this a reasonable position.

However, this is not to say that there are disputes. In the case of the James family, it is my understanding that they are currently seeking legal advice, and in the case of the LCP, there are individuals and organisations in various quarters who have been supportive of it, such as an article in a 2009 edition of the Journal of Clinical Nursing. Therefore, given the seriousness of the issues raised here, I am quite sure you would agree that it is entirely appropriate that the government should seek to restore confidence in the NHS as a whole, and initiate an investigation into the following questions. Namely, to what extent, if any, has familial consent been ignored or overridden in the application of care to potentially terminally ill patients. I am quite sure you will agree that the public is more than deserving of a full and frank answer to that question.

Yours sincerely
(this letter was delivered to the Department of Health on Monday 7th January 2013)

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