Sunday, 7 April 2013

Liverpool Care Pathway - Some Pastoral Advice

The consecutive thoughts of Bishop Philip Egan.
 The Catholic Church in England and Wales has been generally in favour of the LCP since its inception 15 years ago... 
Bishop Egan also spoke about how the determination was made that someone was near death. “Maybe I would just one further concern I have, and that is the medical judgment that somebody is about today is a very vexed and difficult judgment to make. I have had some concerns relating to the actual procedures involved in making that judgment... 
Bishop Egan’s decision to break ranks is understood to have been shaped by his experience of the LCP while serving as a priest in a church near Stockport, Cheshire, before the Pope appointed him to Portsmouth in the summer. 
He became concerned about an elderly man in his parish who had taken 12 days to die on the LCP after doctors withdrew his food and fluids. 
The death occurred within the Stockport NHS Foundation Trust which last year saw 48 per cent of patient deaths on the LCP and the receipt of an award of £113,000 for hitting LCP targets. The Trust was also awarded £191,000 the previous year when 41 per cent of patient deaths were on the pathway. 
In his teaching to the Portsmouth diocese, he advised terminally ill Catholic patients to be deeply cautious about signing Do-Not-Resuscitate forms and suggested they should request drugs that will not deprive them of consciousness. 
He told their relations that if they “hear people speaking about ‘quality of life’, be on your guard”. 
“Insist on being notified before the patient is placed on the LCP and that you are involved in the decisions being taken,” he said. 


His faith commends him; perhaps, not his judgement...

The Liverpool Care pathway must be withdrawn.

Bishop Philip Egan of PortsmouthPastoral Teaching Message in December 2012 (extract) -

THE CARE OF THE DYING

The following is a Pastoral Teaching Message from Bishop Philip to the priests and people of the Diocese of Portsmouth. It was issued on 8th December 2012, the Solemnity of the Immaculate Conception of the Blessed Virgin Mary.

MEDICAL CARE OF THE DYING: THE LIVERPOOL CARE PATHWAY

In 1997, the LCP was launched as a framework to improve the care of the dying.12 It comprises procedures intended to alleviate suffering, and to assist the medical staff set appropriate goals, avoid invasive treatments and follow recognised patterns of palliative care. In theory, all parties are involved: medical staff, patients and relatives. In practice, the LCP is dependent on the skills and experience of the members of the multidisciplinary teams applying it. Staff must reach a judgment that the patient is dying and once made, the patient is put on the pathway. The intention is to relieve symptoms. Often clinical care is suspended, heavy sedation and then terminal sedation administered, patients put to sleep, and eventually life-prolonging treatments and drips withdrawn, even feeding and hydration13. Sometimes beforehand, the elderly, the frail or those with complications are asked if they wish to sign a DNR or ‘Do Not Resuscitate’ order, in case they suffer cardiac arrest or cease breathing.

The LCP is fast becoming the NHS way of dying, with the government offering financial incentives for its adoption. Already in some areas, 1 in 2 terminally ill patients die on the pathway. Its intentions are benign, yet as a pastor, my own experience, together with anecdotal evidence, suggests that what should be supported dying becomes blurred with assisted dying. Medical wards are often congested and busy. It is not easy to make the clinical judgement that a patient is about to die – this is the nub of the issue - although once on the pathway, death usually occurs in an average of 29 hours. There is no legal requirement to obtain patient consent and evidence suggests that relatives are not always informed. Most controversial of all is the withdrawal of feeding and hydration. True, this is not needed in the very last hours of a person’s life. But to withdraw feeding and hydration to bring about death, even if permitted by law for those in a so-called persistent vegetative state, is a heartless act of cruelty towards the weakest and most defenceless, effectively starving a patient to death. It is in effect, as Blessed John Paul said, euthanasia14. In my own ministry I have heard of patients lasting for days before passing away, whilst stories are told of relatives feeding fluids to patients who later recover. All these are reasons for a careful re-evaluation of the LCP and its application in practice.


Bishop Philip Egan of Portsmouth: Catholic Herald -

Bishop Egan welcomes Government move on Liverpool Care Pathway

By  on Friday, 5 April 2013

Bishop Philip Egan of Portsmouth has welcomed reports that the Government will abolish cash incentives rewarding NHS Trusts for placing seriously ill or elderly patients on the Liverpool Care Pathway.

The bishop spoke after Care Services Minister Norman Lamb told bereaved families at a meeting in Leeds that he intended to halt the controversial system of paying hospitals for hitting targets of patient deaths on the pathway.

Mr Lamb was reported as saying that he did not believe any hospital should gain financially from the deaths of patients through the Commissioning for Quality and Innovation (CQUIN) schemes.
He revealed his intentions to stop the payments during the first of a series of meetings with families under the independent review of the LCP chaired by Baroness Neuberger.
“It is important that I respect the independence of this review but I have already made clear that I have serious concerns about the use of financial incentives and that they should only ever be used if they demonstrably improve patient care,” he said in a statement afterwards.
After Mr Lamb’s comments were reported Bishop Egan issued his own statement welcoming the decision.
“I am very grateful that the Government has now set up a review in order to fine-tune and improve the LCP,” said the bishop, who in December announced in a pastoral message to his diocese that he had “unresolved reservations” about the LCP.
“One of my reservations was the payment of financial incentives to hospitals to put patients on the LCP. I worry that this could easily blur motives,” he said.
“I am delighted therefore that the Government is going to stop these payments and thus to avoid any potential confusion.”
The system of incentives has seen six-figure payments made to NHS Trusts that succeed in achieving a set percentage of patient deaths on the end-of-life framework.
Figures released under the 2000 Freedom of Information Act have shown that about two thirds of all NHS hospitals operating the LCP have received payments for hitting targets associated with its implementation.
An estimated £30 million has been paid out over the last three years, with some 130,000 patients now dying annually on a framework designed to make the final hours of life as pain-free and peaceful as possible.
The terms of reference of the Neuberger review state that investigations will be carried out to see if the payments were resulting in “bad practice”.
The LCP typically involves the heavy use of sedatives and narcotics and the withdrawal of food and fluids.
It has become controversial because some senior doctors say it is not scientifically possible to predict when a patient is dying and that prognoses of death are little better than “guesswork”.
This, they argue, means that a high rate of misdiagnosis is inevitable on a pathway which is lethal, with most patients dying within 29 hours.
Hundreds of families are complaining that relatives were wrongly placed on the LCP or that neither they nor the patient were informed of the decision.
One of the critics of the LCP, Professor Patrick Pullicino, a consultant neurologist with the East Kent Universities Hospital NHS Trust, and a Catholic, said that the end of the CQUIN payments was essential.
“It is very important that these CQUINs are removed,” Professor Pullicino said. “But it is only the start of things. The LCP itself has to be stopped.”
The Catholic Church in England and Wales has been generally in favour of the LCP since its inception 15 years ago, however.
It was devised by Professor John Ellershaw, a Liverpool-based Catholic, and supported by Oxford-based Anscombe Bioethics Centre, the Catholic bioethical institute.
The Anscombe director, Professor David Jones, has served as a member of the National LCP Reference Group.
In spite of the recent controversy, Auxiliary Bishop Tom Williams of Liverpool announced in a letter to the Tablet that he thought nurses and doctors who followed the guidelines faithfully were doing God’s work.
Such Catholic defenders of the pathway argue it is not inherently flawed but abuses occur in the way it was sometimes implemented.
Bishop Egan’s decision to break ranks is understood to have been shaped by his experience of the LCP while serving as a priest in a church near Stockport, Cheshire, before the Pope appointed him to Portsmouth in the summer.
He became concerned about an elderly man in his parish who had taken 12 days to die on the LCP after doctors withdrew his food and fluids.
The death occurred within the Stockport NHS Foundation Trust which last year saw 48 per cent of patient deaths on the LCP and the receipt of an award of £113,000 for hitting LCP targets. The Trust was also awarded £191,000 the previous year when 41 per cent of patient deaths were on the pathway.
In his teaching to the Portsmouth diocese, he advised terminally ill Catholic patients to be deeply cautious about signing Do-Not-Resuscitate forms and suggested they should request drugs that will not deprive them of consciousness.
He told their relations that if they “hear people speaking about ‘quality of life’, be on your guard”.
“Insist on being notified before the patient is placed on the LCP and that you are involved in the decisions being taken,” he said.


Bishop Philip Egan of Portsmouth: Vatican Radio -

2013-04-04 17:41:56 

Bishop Egan applauds health policy changes


Vatican Radio) The British government has revised its rules on end-of-life care, and set up a review of the “Liverpool Care Pathway” (LCP) – a program that coordinates palliative services for those in the final hours and days of life. 

“The Liverpool Care Pathway is a process, a set of protocols to care for the dying in our hospitals, particularly in the National Health Service and in care homes. But it’s been, in the last, well really in the last 18 months a lot of controversy regarding it,” said the Bishop of Portsmouth, Philip Egan, in an interview with Vatican Radio’s Christopher Wells.

Bishop Egan said, “It’s good to have care of the dying conducted in this way in our hospitals.” Nonetheless, he expressed reservations about some aspects of the program. In particular, Bishop Egan had said he was concerned about the government offering financial “incentives” to place people on the Liverpool Care Pathway. He said he was “delighted” with the government’s decision to stop those payments. 

He also expressed his gratitude that the government was reviewing the procedures of the LCP. 

He spoke about some of the other concerns with the program. “One of my other concerns has been that sometimes relatives of terminally ill patients haven’t been fully involved in the decision making process and the care, the medical care and also of course the spiritual care that needs to go with that, particularly for Catholic patients. A few months ago, the government here implemented a review of the Liverpool Care Pathway, and I think this is one of the concerns that they seem to acknowledge and seem to be involved in.” 

Bishop Egan also spoke about how the determination was made that someone was near death. “Maybe I would just one further concern I have, and that is the medical judgment that somebody is about today is a very vexed and difficult judgment to make. I have had some concerns relating to the actual procedures involved in making that judgment. But of course I’m not a medic and I’m not an expert. I just speak as a concerned pastor.”

Despite some reservations, Bishop Egan spoke highly of the program, and especially about caregivers. “I think our hospitals, our medical staff, and those who care for the sick and the dying do an absolutely magnificent job. And I’m very keen that we concentrate particularly in our bidding prayers at Mass, the intercessions, that we frequently pray for the sick and for those who care for them.”

He said he hope the government review would result in better care for the dying. “As I’ve also said before, it’s a controversial thing, this LCP, but nevertheless its intentions are truly honourable ones and I’m just very hopeful that the present review and one or two adjustments will fine-tune it and make it even better.”

Listen to the full interview of Bishop Philip Egan with Christopher Wells: Download the audio file on Vatican Radio -

video

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