Liverpool Care Pathway - Whither Responsive Care?

"Never give in; never give in; never, never, never..."

She wanted "to fight the cancer with all of her might, and until the end."

This is from a discussion blog to the USC Health Sciences Campus –

Date: Thu, Apr 29 2004 2:17 AM From: loveelk@yahoo.com To: DoktorMo@aol.com

Right now I don't have a good attitude about anyone who talks about dignity and quality of life. My Mother recently passed away from cancer. Yes, she was terminal, but she wanted "to fight the cancer with all of her might, and until the end" were her words. She wanted to die a natural death without any help from Dr's and their drugs. I found that the "one" famous drug that Dr's love to use is "morphine". My Mom slipped into a coma just before her death, as all people I think do? But the Dr's were growing weary of how long her death was taking. They kept insisting that they give her "just a little bit of morphine to ease the pain and make her comfortable" Why on earth would my Mom need morphine if she was in a coma? There is no way she could have felt any pain, and how much more comfortable can One get than to be in a coma?

Finally, the hospital's Attorney and Vice President of the hospital came in and yelled at our family just a few days before my Mom's death. They told us that we were irrational and my Mom needed a " Advocate" to protect her rights.. The board of Ethics called us on the day she died and by making this call, Noone was in the room when she passed. The Dr's forced us into a decision of withdrawing life support, therefore practicing , "Euthanasia" We wanted our Mom to die at her will...when her body gave out, not when the Dr's decided it was time for her to go.

My last words to people who talk about quality of life ought to be a shame of themselves for even viewing an Elderly person by how much she/he accomplishes in a day. Even if all my Mother could do was simply sit in a chair and look out the window, maybe needed help with eating ...etc...this was quality enough for me. As we all become older we will find our quality of life diminishes. So I ask you, "should someone take your life to be lacking with dignity and quality where they take it upon themselves to have you killed?" simply because they don't find your life to be worthwhile any longer? God says that quality of life is not judged by how old or sick you are...He makes the decision, not the Dr's. People need to take a good long look at their own lives and realize that one fine day they will be old and sickly. Dr's do not care..they would rather end your life than help you. And it is simply due to money. the older one is, the more medical attention one needs, more tax dollars at work.

The government and the Dr's work together..they call this "population control". I have seen many elderly fall ill and once they have seen the Dr. and put in the hospital, they may as well say good-bye. The Dr's of today just as soon kill you. The old wives tale of helping your neighbor are long gone, now it is power and money. Here in MT, we have a saying that goes like this, "You may be safer seeing the Veternarian, than going to the Dr." Quite a few people die over a simple surgery ..makes you wonder if you can trust the health care system any longer?

I haven't quite decided if it is safe to see my own Dr. any longer after what I have seen take place in these hospitals here in Montana.? Euthanasia is practiced whether you want to believe it or not..by even your own Dr.

This correspondent asks, "Why on earth would my Mom need morphine if she was in a coma? There is no way she could have felt any pain, and how much more comfortable can One get than to be in a coma?"

Good question. Where there are symptoms, those symptoms should be addressed. That is so for all care. How may 'end of life care' be any different, assuming EoL may be determined with any scientific accuracy?

The correspondent proceeds to say, "Dr's do not care..they would rather end your life than help you. And it is simply due to money. the older one is, the more medical attention one needs, more tax dollars at work."

Good point. This is  Forbes –

Critics of the Obama administration’s recent health care reform rightly focus on the $1 trillion cost of the legislation and fears that it will add to already unsustainable federal health care commitments for Medicare and Medicaid. Defenders point to the legislation’s cost-saving provisions, like the Independent Payment Advisory Board (IPAB) which, starting in 2014, will recommend automatic Medicare spending cuts if costs grow faster than an average of the consumer price index and health care inflation.

For the fiscally minded, so-called “automatic” cuts may sound good, but in this case they’re a mixed blessing. That’s because their impact is likely to fall first on pharmaceutical or medical-device innovation (hospitals and physicians are exempted from IPAB’s knife until 2020). In fact, one likely IPAB recommendation–embraced by Dr. Donald Berwick, the new administrator of the Centers for Medicare and Medicaid Services–would be for Medicare to create a new “cost effectiveness” standard for covering medical products. Technologies that didn’t pass this test would receive less generous Medicare reimbursement.

“Cost-effectiveness” is economic jargon for what appears to be the self-evident goal of trying to improve patient health at the lowest cost.

This is pre-Obamacare 2004, but the whole point of Obamacare is that the Federal health care commitments for Medicare and Medicaid (the 'tax dollars') are "unsustainable". The IPAB will follow the example of NICE in healthcare rationing. Those who are the biggest drain on available resources will begin to feel the pinch. Come on, now, be fair... But those who are the 'biggest drain' are the most needy.

In the UK, packs of Paracetamol are restricted to two packs of 16 pills per customer, yet, morphine is dolled out as protocol in EoLC.

In the US, a bottle of Acetaminophen (Paracetamol) containing four to five hundred pills can be bought over the counter at drugstores, but the US and the UK, care of Don Berwick, Si' Stevens, old Uncle Zeke Emanuel and all, are moving closer and closer, so it's all a blur...

Here's doctor choice, for instance...

EZEKIEL EMANUEL: The president never said you were going to have unlimited choice of any doctor in the country you want to go to.
WALLACE: Wait. No. He asked a question. If you like your doctor, you can keep your doctor. Did he not say that, sir? 
EMANUEL: He didn't say you could have unlimited choice.
- Fox News 

Zeke, ever the master of the gobblededoublegook.

And this is NewsMax Health –

The U.S. Food and Drug Administration has proposed stronger safety language on labels of long-acting and extended-release opioids in response to an epidemic of overdoses and deaths from the widely used pain medicines.

The labels need to highlight dangers of abuse and possible death, as well as risks to newborns of mothers taking the medicines, the agency said on Tuesday. 
Opioids include formulations of morphine, oxycodone and fentanyl. One of the best-known opioids is Oxycontin, a long-acting form of oxycodone. 
Some 16,651 people in 2010 died from overdose deaths related to opioid abuse, the FDA said, including long-acting formulations.

Updated language in the drug labels will stress the medicines are meant for pain severe enough to require daily, round the clock, long-term opioid treatment, and only for those who have not had adequate pain relief from alternative medicines.

Fact: Morphine kills; but morphine is still administered as protocol in EoLC.

The FDA has issued warnings in regard to opioids, Fentanyl in particular and disposal of Fentanyl patches, which contain a high reservoir of Fentanyl.

Fentanyl has a high risk for abuse and severe, possibly fatal, breathing problems. Do not use transdermal patches unless you have been regularly taking moderate to large amounts of narcotic pain medication. Otherwise, it may cause overdose (even death). The risk for harm is higher if you use the wrong dose/strength, or if you use it along with other drugs that might also affect breathing. The risk for breathing problems might also be higher when you start this medication and after a dose increase. Get medical help right away if you notice unusual slow/shallow breathing.
- Web Med 

Fact: it is not scientifically possible to diagnose dying, but this still proceeds using the Barton method, up to one year's hence, via the GSF Surprise Question.

Where there are symptoms, those symptoms should be addressed. That is so for all care. This CNN report, from February of this year, demonstrates that this is not so -

London (CNN) -- In the 23 years since he tried to break up a robbery in central London, Ian Semmons hasn't spent a day without severe pain.

The fight left Semmons with multiple fractures, including a broken back and two shattered ankles. He had a head injury so severe, doctors put him in a coma and kept him there for a month to control the swelling in his brain.

"I spent nine months in hospital and then 12 months in a rehabilitation center, where I was basically rebuilt," Semmons says. "But nothing was done to treat my pain."

His regular doctor, a general practitioner with Britain's National Health Service, offered little for the pain despite his complaints. At the time, patients in Britain's government-run system such as Semmons weren't able to switch to another doctor. Unlike patients now, he was stuck.

Semmons' experience highlights a reluctance of many UK doctors to treat pain aggressively, including a reluctance to prescribe painkillers, especially opiates -- the rampant use of which in the United States is widely described as an epidemic.

And so, we come full circle. The correspondent asks, "Why on earth would my Mom need morphine if she was in a coma? There is no way she could have felt any pain, and how much more comfortable can One get than to be in a coma?"

Why is there not just responsive care, not 'pathway'? The misleading title of the LCP Review remarked as much. What is this obsessive pursuit of 'EoL' care? The correspondent answers this ably and well.

Historical footnote:
Morphine was used by the Ottomans in their Armenian genocide and, later, in the T4 euthanasia programme at Hadamar.