A whole generation of young doctors
has been conditioned and programmed to accept the validity of what is
an unscientific premise, that it is possible with a degree of
certainty to identify various presenting signs as an indicator of dying.
Prof Pullicino, consultant neurologist at East
Kent Hospitals University foundation trust, has cited previously what was
reported in yesterday's Telegraph and is mentioned at length in tonight's
Dispatches as the case in point that a physician's 'diagnosis' of dying, at
best, is a prognosis, a consideration of what may be a likely outcome, that is
bettered and bested by most TV weather forecasts.
This is yesterday's Telegraph -
One of Britain's leading neurologists has revealed his fears about the use of the Liverpool Care Pathway as he disclosed how one of his patients survived for 14 months after being taken off it.
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| Once discharged from the Pathway Mr di Francisci spent 14 months enjoying family life before his death in March 2011 Photo: Warren Allott for the Telegraph |
8:30AM GMT 03 Mar 2013
The intervention from Prof Patrick Pullicino comes amid mounting concerns over the approach, which can involve the withdrawal of drugs, fluids and food, and the administration of powerful pain relief to patients who are believed to be dying.
An independent review of the pathway, and of six-figure payments which have made to NHS hospitals for meeting targets to place people on it, is now under way after it was ordered by ministers.
Prof Pullicino, consultant neurologist at East Kent Hospitals University foundation trust, said the system was open to "terrific abuse" because doctors had no objective way of forecasting death, and often hastened it, by stopping treatment and sustenance.
Weekend staff at Kent and Canterbury Hospital decided to withdraw treatment and food and drink from Sammy di Francisci, 71, without informing his family - nor Prof Pullicino, the consultant in charge of his care.
Mr di Francisci's daughter told The Sunday Telegraph that she visited her father, who had suffered a series of strokes and seizures, to find all feeding and medication tubes had been removed.
Although she pleaded with nurses to call a doctor to restart treatment, they ignored her pleas, insisting that her father was dying, and could not be helped, she said.
As he weakened, a priest was even called to administer the last rites.
When Prof Pullicino arrived on the ward on the Monday, he knew nothing of the decisions taken in his absence - and agreed with the pensioner's family that treatment should be urgently restarted.
Mr di Francisci quickly began to recover and was soon discharged to his home, where he spent 14 months enjoying family life before his death in March 2011.
The consultant neurologist said the case demonstrates that doctors should not be allowed to forecast death, which became a "self-fulfilling prophecy" once treatment and sustenance were withdrawn.
Prof Pullicino said: "There is no objective criteria to say whether a person is dying or not - there is no scientific way to know, and that means the system is open to terrific abuse.
"If you stop treating someone for their condition they are unlikely to improve. If, on top of that, you sedate them heavily, you are unlikely to see any improvement even if it does occur. That is why putting patients on the pathway becomes a self-fulfilling prophecy."
The consultant said he believed that doctors taking such decisions were often making a judgement about the patient's quality of life, not about whether they were close to death.
"Quite often, there will be elderly patients in hospital who look absolutely terrible, and anyone might think they are at death's door. Yet they can recover quickly: doctors are simply not capable of knowing who will improve," he said.
Each year around 130,000 patients are placed on the pathway, which is supposed to follow principles of care developed in hospices, by allowing patients to die in comfort and dignity.
Critics say the approach is being used to hasten the deaths of the terminally-ill and elderly, in a form of "back-door euthanasia".
The Government ordered a review of the pathway after increasing concerns about its use, and about cases in which families said they were not consulted or even told when food and fluids were withheld from their loved ones.
In December, The Sunday Telegraph disclosed the findings of a national audit, which found that around half of those placed on the pathway were never told that efforts to keep them alive were about to be stopped.
However, many doctors and charities for the dying have come to the defence of the approach, which they say is intended to help ensure that people can die in dignity and comfort, instead of enduring invasive and painful treatment.
On Friday a survey of more than 500 doctors carried out by the British Medical Journal found that 90 per cent believed the pathway was the best way to care for dying patients. But one in five of those working in palliative care said they were not able to judge when a patient was dying.
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| Mr di Francisci's daughter, Rosaria Squire, with her family (Warren Allott for the Telegraph) |
When his daughter Rosaria Squire, 40, from Deal, in Kent, arrived for her daily visit, all his feeding and treatment tubes had been removed. She begged to see a doctor, but nurses insisted her father was dying. No mention was made of the care pathway, she said.
She said: "It was heartbreaking. I knew it wasn't time for him to go. I said to the nurses, 'he's not a number, he's my dad; he's a husband, a grandad'."
It was not until Prof Pullicino arrived for the Monday ward rounds, that the intervention was made, and treatment restarted.
She said: "We saw him and we said what is happening, why is dad not getting medication, or fluid? By then dad's eyes were sunken, his skin was yellow and his mouth was crackling dry."
Within two weeks of being taken off the pathway, her father was at home with her mother Maria, smiling, speaking, and sitting in the front room watching television, Mrs Squire said.
"He found joy in life, he was a real family man, so close to my little daughters, Sophia and Natalia, who were three and nine then. Sometimes he was able to sing to them, and other times we would take him on trips to the beach," she said. "Life was precious."
His wife Maria, now 74, was able to look after Mr di Francisci, a retired insurance worker who had come with his wife from Sicily in 1962, at home.
Mrs Squire said: "Mum had been so tremendously upset when the doctors stopped treatment, they loved each other so deeply. She was overjoyed when he came home."
Mr di Francisci survived for 14 more months, before falling ill with pneumonia, and dying in March 2011. Again, the pathway was used. But this time his daughter felt it was used appropriately. "By the end he was very reliant on oxygen, and he was struggling to stay alive. In the end the doctor who was treating him said they thought it was best to stop the oxygen, and he died a couple of hours later."
She said she felt comfortable with the way the decision was taken.
Mrs Squire said: "I don't disagree with the pathway itself, it is the way it is being used that concerns me. This time the doctor involved knew my dad, and discussed what was going on with us."
Prof Sam Ahmedzai, a leading palliative care doctor, said he was worried that "inhumane" decisions were being taken by doctors who did not know the patient being discussed, and were in a poor position to make judgements about their prognosis.
He said: "What often happens though is that the decision is taken out of hours, at weekends, basically by strangers who have never seen that patient before and never will again."
It was "unforgiveable," said Prof Ahmedzai, professor of palliative care at the University of Sheffield, for life and death decisions to be made in such a way.
Advocates of the approach include Dr Kate Granger, 31, a terminally-ill doctor, who specialises in care of the elderly and who was diagnosed with a rare form of cancer at the age of 29.
She told Dispatches: "I've always thought of LCP as a really good process to help patients at the end of their lives to have standardised good quality palliative care - I haven't changed that view since I got cancer myself."
Dr Granger said she was fearful that if the pathway was abolished, she might suffer a worse death. She said: "What would happen to me? Would I get the comfortable serene death I would like? I'm not sure."
* Death on the wards: Dispatches. Channel 4, Monday, 8pm
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