Saturday, 5 October 2013

Liverpool Care Pathway - When The Prescription Is EoLC

A vacant vessel makes most noise. And these vacant vessels expound vacuous truths... God help the senior citizen lacking poise!

You never see the glass half empty; you always see the glass half full. Otherwise, you’re just giving up.

So many have been diagnosed not with a terminal illness but with 'dying'.

Once you're on the road, you keep your eye on the the road. Once the path is chosen, there is little chance of deviating from it.

'Holistic', a word filched from 'alternative' medicine, is bandied and dangled in connection with EoLC. In holistic medicine, however, the reference is not to the road but to the map.

Every patient is an individual and every patient is an individual case. 

Whatever ‘signs’ the EoLCP defines as being an indication of approaching and encroaching death, none of these ‘signs’ are so atypical that they can be excluded from any other cause. Once on the pathway, the balance will tip toward excluding other possible causes.

This is the Northern Devon Healthcare NHS Trust –
End of life care  
The doctors and nurses will have explained to you that there has been a change in your relative or friend’s condition. They believe that the person you care about is now dying and is in the last hours or days of life. 
The End of Life Care Plan is a document which supports the doctors and nurses to give the best quality of care. All care will be reviewed regularly.
You and your relative or friend will be involved in the discussion regarding the plan of care with the aim that you fully understand the reasons why decisions are being made.
You and your relative or friend will be involved...

Hang on. Shouldn't that be 'asked'...?

Aren't we allowed to seek a second opinion...? Have they set themselves up as judges and is the judge's decision final...?
Medicine that is not helpful at this time may be stopped and new medicines prescribed. Medicines for symptom-control will only be given when needed, at the right time, and in just enough quantity to help the symptoms. 
This is pure LCP. The effect of the 'new' medicines may be to suppress diet and breathing. That very outcome may be interpreted as a sign that the diagnosis is correct and reinforce the conviction to stay on track. 
Loss of interest and a reduced need for food and drink is part of the normal dying process. When a person stops eating and drinking, it can be hard to accept even when we know they are dying.
Myoclonic jerking is seen more frequently at the end of life, but its appearance can be related to at least 21 other medical conditions. Opioid-induced myoclonus is also not uncommon. Requiring a diagnosis of ‘dying’ such as that which EoLCPs expect of the clinician is difficult, therefore, and fraught with peril.

This is from the Baker Report - Final version : October 2003 –
Agitation, confusion and myoclonic jerks occur as a consequence of opiate toxicity. These features may be interpreted as un-controlled pain, leading to the administration of more opiate medication. The consequences are increased sedation, dehydration and further toxicity (O’Neill and Fallon, 1997)
NPSA NHS Patient Safety
Macmillan, forthright and thorough: "Good pain relief requires regular dosing rather than a vague direction 'as required'." And in 'just enough quantity'. And despite numerous Government health warnings...

See -
Opioid Medicines - National Patient Safety Agency  
Over-sedation is the least-recognized error (16%)

And this is AITSE ( American Institute for Technology and Science Education) -

...morphine suppresses hunger, thirst, and the digestive processes. Since the patients being given morphine while in comfort care do not feel hunger or thirst and are not being supplemented with IV fluids, they quickly dehydrate. Without water, even a healthy person will die within a week. Morphine also suppresses breathing. Many patients in comfort care have grown tolerant of opiates and require significant amounts of morphine. And it is sometimes difficult to know when a large dose becomes a lethal dose. The side effects of morphine make it difficult to draw the line between keeping a person comfortable and helping them to die, the latter of which is illegal in most states.

According to the Hoag Presbyterian Hospital brochure, the staff is there to help you during your loved one’s last hours, when the patient experiences symptoms that they say are “merely the natural progression of the body as it prepares for the final stage of life.” These symptoms may include, among others, a decrease in appetite and thirst, confusion, changes in breathing patterns, and constipation. Note the similarities to the side effects of morphine? If the morphine is needed to control pain, then accepting the side effects is necessary. But, is morphine necessary?

Not always and this is the second issue. According to hospice nurse Nancy Valko, R.N., in her article, “Sedated to Death,” patients are often given morphine, not to deal with intractable pain, but for the convenience of the health care workers. She gives the example of a radiologist with a brain tumor who decided that he wanted to die and stopped all medication, nutrition, and hydration. After nine days without food or water he became agitated, and so was given high levels of morphine—and died. Was this just comfort care or was it euthanasia?

Valko also points out that comfort care or terminal sedation, which is when the patient is given enough drugs to render them unconscious for the remainder of their lives, is not always only reserved for those who are terminal or who wish to die. It is also administered to victims of strokes, who usually are not in pain and may well recover—unless the morphine and dehydration kill them first.  In fact, comfort care is pretty much what is practiced in the Liverpool Care Pathway, through which 130,000 patients, children included, die every year, even those who could recover from their illness.  Of course, in the case of the UK, it saves the government money–and it is under investigation. In the case of the USA, it benefits Medicare and the insurance companies.

But, assuming comfort care is used ethically and legally, is it really comfortable? This is the third issue. Let’s have a look at a description of comfort care by a proponent.  Robert J. Webb, M.D., informs us “in studies with volunteers dying from different diseases, …dehydration and malnourishment were not shown to be painful.” He asserts “the lack of food and water actually promoted comfort…” Anyone else see the problems here?

One wonders how those conducting these studies gathered their data. It is rather difficult to question dying or unconscious or, for that matter, dead persons about how they are feeling. In addition, assuming that these studies were conducted in the standard manner, with controls, how did the scientists quantify the level of pain or discomfort that the two groups of patients (dehydrated and hydrated) were experiencing? And if, as he suggests, the dehydrated patients did better, did he tell the hydrated patients, “tough luck—you were randomized to the wrong group?” Obviously, this claim is violating AITSE bunk detecting principle 5.  The author is making claims about something that cannot be tested, much less tested scientifically. According to a comprehensive review  by Frederick Burge, MD, it is difficult to design good studies on “very sick people,” as can be imagined.- Caroline Crocker, MSc, PhD, and Joseph Kezele, MD
Further reading -
Liverpool Care Pathway - Fallen Unto Iniquity

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