Friday, 28 March 2014

Liverpool Care Pathway - Advancing The Will To Live

When every day is a bonus and every hour is a milestone; when every minute is a moment cherished and every second is counted on the clock...

Is it more appropriate to promote the 'Living Will' or to advance the will to live?

It’s instinctual. You see someone in trouble and you rush to their aid. It’s just what you do.

We are not machines. We are not programmed by some machine coded instruction to act or not to act. We are plunged into action by what needs to be done because it's right and because, "A man’s gotta do what a man’s gotta do..."

Was that the all-time action hero, John Wayne...?

It's supposed to be a quote from Stagecoach.

No, it’s in Hondo Wayne says, "A man oughta do what he thinks is right".

Charlton Heston says, "A man must do what he must do" in Three Violent People.

Perhaps we’ll go with Heston, then. It is fitting that we should because he appears with the iconic Edward G Robinson in Robinson's last picture epic, the classic Soylent Green, here mentioned in these pages -
Liverpool Care Pathway – The Protocol Of Choice
It is instinctual. Today's first responders may be trained in the new protocol of DNACPR but, when you arrive on the scene and see every effort frantic being made, what else can you do but throw yourself in there with that struggle to do what you gotta do...?

Here is the Bradenton Herald –


BRADENTON -- She was 95, had no pulse, was in full cardiac arrest and not breathing. 
But Bradenton Police Department Sgt. John Negron said he saw all-out effort to save Jennie Sanders when he arrived at the residence in the 1200 block of Tidewater Court in Bradenton at 3:48 p.m. Sunday, Jan. 26, including officer Jeremy Telles frantically doing chest compressions. 
"Mrs. Sanders was on the bedroom floor and Jeremy was doing chest compressions while Mrs. Sanders' son-in-law was giving her breaths," Negron said. "Jeremy had been there five minutes before I got there and I yelled, 'Let me swap out.' " He said, 'OK.' Then I did chest compressions."  
After ten minutes, there being no response, the family was asked if there was a DNR order. The family urged the effort to continue.
Emergency medical services workers from the Bradenton Fire Department arrived and injected the patient with fluids, while Negron and Telles kept working in tandem on chest compressions.
Negron said he was
...reminded of his wife, Violette's father, Frederick Schneider, who died in his recliner in Spring Hill in October, leaving Violette no chance to say goodbye.
There was a pulse and Mrs Sanders started breathing. Time is of the essence. You don't think; you act...
"I think because we started so quickly and worked so steadily, there was oxygen still circulating even though we couldn't get a pulse," Negron said.
Mrs. Sanders was taken to the Manatee Memorial Hospital. The frantic determination had produced a result.

Mrs Sanders survived only a day before passing away.

So, what was it all for...? Because that’s what you do and you have to know in your heart of hearts that you have done all that you can do. And every day, even just one day, is a bonus.
"The family was very grateful for the officer's actions because it allowed them the opportunity to properly pay their respects during the interim," Radzilowski said. 
Negron said he was deeply moved by the experience of bringing a person back to life.
"It's satisfying knowing we gave this family an opportunity to say goodbye to their loved one," Negron said. 

Negron and Telles were both named Bradenton PD Officers of the Month for March.

This would not have sat well at all with the Lakhani Recommendations and the EoLC Programmes in the UK.

It is likely that this would not have happened here in the UK. The EoLC Strategy has done its work and done it well in changing attitudes and perceptions. This work continues and is being reinforced with the subtle stratagems of the Dying Matters Coalition.

It is likely that this would not have been possible with such policies set in place of denying hospital re-admissions and downsizing care.

We are only half way there and there is much work to be done. Think what will have been achieved in another five years...!

Changing attitudes and changing perceptions: this is the grand design.

America, this is the face of things to come.

To this family, a day meant everything. Think what four months would mean...


This is Mail Online –
Thousands of men with advanced prostate cancer could be denied a new drug by the NHS rationing body.
Radium-223 extends life by nearly four months and improves quality of life for men whose cancer has spread to the bones.
In the latest blow to men with prostate cancer, the National Institute for Health and Care Excellence (Nice) has issued a draft decision not to recommend its use on the NHS in England and Wales.

More...? You want more?
You wicked, wicked boy. Not four months, not one day more shall you have!  - Apologies to Dickens

In the fictional, resource-stripped world of Soylent Green they have a cost-effective EoLC Strategy set in place. It is at once effective and sympathetic; it is an EoLC and euthanasia programme rolled into one that provides dignity, respect and a grand send-off.

Fittingly Communitarian, no body parts are wasted following death. Soylent Green is people!

Fittingly Communitarian, back in the real world of the one percent, the NCPC and the Dying Matters Coalition, organ donation is incorporated into ACPs.

"Vulnerable older people" are being given the hard sell. ACPs are actually being marketed as "end of life rights".
"With this new information I can now make a fully informed decision on the type of care I want and don’t want at the end of my life and I have the knowledge to take control over my own care, providing me with the peace of mind to know that I have an end of life care plan in place for when the time comes." Jan's Story
As much as we might like it so, it may not be so that we will die as we might like to. The future cannot be safely predicted; it is full of uncertainty. The unknowable and the unforseen frightens those who market death as a positive life option and ACPs as a positive safeguard. They urge us to "talk about it" but, actually, they do not wish to talk about it; they are themselves afraid of death.

It is not possible to determine in advance what specific medical treatments should be necessary or optional or under what circumstances that should be so. ACPs oversimplify the decisions that are being taken, writ in stone, in black and white as legal documents to be complied with for hypothetical future medical scenarios.

There are very real risks that circumstances will arise that would have prompted a different decision had we had prior knowledge and thought it through and that our intention will not accommodate for every possible medical situation and circumstance nor permit manoeuvre for those who must comply with and act upon these 'Last Wishes'.

The unknown and the unknowable are not privy for us to see.

America, these documents are with you and they are called the POLST.

This the Complete Lives System for treatment priority...

This actually matches well with Jacques Attali's outrageous statement -
"As soon as he goes beyond 60-65 years of age man lives beyond his capacity to produce, and he costs society a lot of money...euthanasia will be one of the essential instruments of our future societies."
These documents concern themselves with over-treatment. This befits the Communitarian compartment into which the elderly are dropped. It is clear and apparent that the elderly should not fear the prospect of over-treatment but, rather, the real and ever-present danger of under-treatment.

There is an Hideous Strength at work. It is clear and apparent that the elderly should fear the prospect of an active and enthusiastic euthanasia movement disguising itself and portraying itself as a benefactor of rights.

Medical authorities and courts commonly and frequently intervene to insist upon withdrawal of treatment, including nutrition and hydration.

Rather than a Living Will, it is more appropriate to advance and encourage the will to live.

Further reading -
Liverpool Care Pathway - A Utilitarian Pathway 
Liverpool Care Pathway - Making The MOLST Of Your POLST
Liverpool Care Pathway – An Hideous Strength
Liverpool Care Pathway – The Prophesies of Ezekiel?

Sunday, 23 March 2014

Liverpool Care Pathway - Crossing The Rubicon

When the die are loaded, they will roll however the House wants them to roll.




How the question is put will determine the response...

Do you really want tubes coming out of you...?

ANH (artificial nutrition and hydration) is defined as “treatment” in the LCP and it is GMC guidance that decisions about whether this should be used should be made in the same way as for other treatments, such as CPR.

This originated in the Lords’ ruling in the Tony Bland case (Airedale NHS Trust v Bland [1993] AC 789).

A majority reasoning in that case was that Tony Bland had no “best interest”. My Lords, that being the case, is it in the true spirit of that ruling to apply it in cases where there is "best interest" and, particularly so, where that "best interest" is determined by those who have it within their grasp and power to withdraw or withhold such "treatment"?

The formulation of death pathways such as the LKP, which has been referred to as a "toxic brand", and their rolling out across the NHS has cut lives short and wrought such horrors as those witnessed by Mr. James McElwee whose petition, 'When Someone is Denied Food and Water it is State Sanctioned Murder', you may find a link to opposite on Change.org.

Eyeballed for the Surprise Question aka The Barton Method, the frail elderly are being fingered for PCRs (Palliative Care Registers) aka the 1%, groomed to downsize their care expectations and draw up ACPs (Advanced Care Plans).

As if that were not sufficient, assertive outreach teams are now plying their trade seeking out “vulnerable older people” to sign up to ACPs. A pro-euthanasia group has somehow conned the Lotto to provide the funding and Age UK to provide the means to do this. They call this "advocating".

ACPs are,typically, documents which record what may not be done, such as CPR as advised by the Lakhani Recommendations. They call this respecting "dignity".

Discussions will proceed, questions asked. How these questions are put will determine the response...

Do you really want tubes coming out of you...?

Those tubes could be to supply the very basics of life; not anything the average person would ever consider as "treatment". 

The only reason that tube feeding has been identified as a ‘treatment’ is so that it can be withdrawn or denied. It all goes back to that fateful decision in 1993.

The noble lords may, perhaps, have had their ears bent by a similar decision in the States. This was the Nancy Cruzan case (Cruzan by Cruzan v. Director, Missouri Department of Health [1990] No. 88-1503). In that decision, it was accepted that tube feeding was a treatment but that there was no "clear and convincing" evidence of Cruzan's wishes.

Thus, the decision went that Bland had no "best interest", hence no wishes to influence the decision. Now, that's really loading the die!

An outcome of the Missouri case was the creation of ACPs. A court order finally settled in favour of Cruzan by Cruzan upon production of the evidence sought.

The Supreme Court held that it is legal and ethical to allow a treatment to be stopped if it no longer meets the patient's goals of care.

"Care"...

It would be generally accepted that care has to do with concern for welfare, the provision of what is necessary for health and the maintenance of health. A goal of care, then, is to maintain life, surely...

It follows logically that, since removal or denial of ANH will result in loss of life - death, it may not be properly stopped under that proviso made by the court.

Likewise, in the absence of an ACP and where it has not been determined that there is "no best interest", is it in the spirit of the Bland ruling to determine that it may be in the patient's "best interest" to die? Is this part of the push to put euthanasia onto the statute books? Exactly where will a Euthanasia Statute lead us...?

Typically, sedation is accompanied by withdrawal of treatment protocols, including ANH (Artificial Nutrition and Hydration), upon initiating a Death Pathway.

However...
"... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."Gillian M Craig
And, whilst treatment protocols are withdrawn, it is stated not to be a goal of care to hasten or to promote death. That is always a point of emphasis. 

However...

That is precisely what such action will incur. In such cases where death is imminent, the body is shutting down and is unconcerned with nutrition and hydration, but this is impossible for the clinician to determine with any certainty or accuracy and to deny ANH is, therefore, a potentially disastrous course upon which to purposefully embark.

Starvation unto death is, surely, a 'cruel and unusual punishment' to mete. To witness someone perish thus must be almost as harsh as to experience it. How does this affect the 'care giver'?

This is the American Journal of Hospice and Palliative Medicine –
The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation.


It would be logical to assume otherwise but familiarity does, indeed, breed contempt. The perception of ANH withdrawal amongst 'carers' actually improves with the experience of inflicting it.

This is Consultant 360 –


NEW YORK (Reuters Health) - Nurses and other caregivers who have dealt with withdrawal of artificial nutrition (AN) for palliative care patients have a better perception of the process than those who have not previously encountered it, according to a new study from France.
A 2005 French law says AN and artificial hydration are medical treatments that can be refused by patients and withdrawn by practitioners, Dr. Benoit Leheup of the Metz-Thionville Regional Hospital in Metz and his colleagues note in their report.

Clinical guidelines commissioned by the country's National Federation of Comprehensive Cancer Centers state that AN is not justified for patients with a life expectancy of less than three months, or a World Health Organization Performance Score of two or higher.
"It certainly seems true to me that those who have strong anti reactions to the idea of withdrawing ANH are reacting much less to the medical/nursing realities than to the symbolism. So it would not be surprising that an 'anti' feeling would be less prevalent among those with actual clinical experience of withdrawal," Dr. Brody said via e-mail.
The issue of the ethics of AN withdrawal in palliative care has largely been resolved in the United States, Dr. Keith Swetz, an associate professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minnesota, said in an interview. Dr. Swetz studies issues in end-of-life care, and reviewed the new findings for Reuters Health. 
"This is one area where the American legal system at a national level has already made a decision on this. That is that the withholding and withdrawal of life-sustaining treatment is permitted and the provision of artificial nutrition and hydration is a medical procedure," Dr. Swetz said. "The Supreme Court in 1990, in the case of Nancy Cruzan, has said that it is legal and ethical to allow a treatment to be stopped if it no longer meets the patient's goals of care." The Cruzan case specifically addressed the issue of AN.
Once that first step is taken, then the next - and each successive step - becomes easier... 

A man, trained to protect and serve life, recalls how his moral perspective was turned to apply to the task at hand. When the unacceptable becomes the routine anything is possible.

Read further -
Liverpool Care Pathway - Somewhere... Is There Erewhon?
Whither are we being led?

Are we but halfway there; then, what shape are things to come, as, step by step, the unthinkable becomes the mundane and commonplace?

Dame Bakewell, once more into the breach, rallies the cause. On Ham & High, Bakewell laments she may not choose her place and time or mode of death. Nothing in life certain. We may be out for a spin tomorrow and...!!!

The Baroness reserves euthanasia for those select few who are suffering terminal pain and terminal illness. Once boundaries are crossed, however, everything is in question.

This is Bakewell in The Telegraph -
“People don’t want the problem of the elderly,” says the 79-year-old baroness. “Everyone would be pleased if the old just went away. Except perhaps their own granny. She can stay … as long as she shuts up, then leaves them lots of money!”
This is shifting the onus of care. There is many a granny going to buckle under the pressure of the resentment she is going to feel...
"alea iacta est!" (The die is cast)
- Julias Caesar 49 BCE

Friday, 21 March 2014

Liverpool Care Pathway - What Is To Be Done...?

A coherent and controlled programme, comrades, is the only way forward!




One crucial problem is a chronic shortage of beds.
"The central issue the NHS faces – demand for healthcare outstripping its supply – is by no means unique to this country.
"The ageing of the population and constant, expensive, technological progress means the NHS will always be in a state of crisis.”
- Neurosurgeon, Henry Marsh 
What is to be done...? (Vladimir Ilyich)
In the past, I would jump up and down and shout when we had no beds and we would start anyway.
A bed was always found because one had to be found.
- Neurosurgeon, Henry Marsh
That was when doctors were motivated by urgency and heroic deeds, and saving lives was at the top of the agenda...

The apparatchiks have stormed the Winter Palace and the world has been turned on its head. Power grows out the needle of a syringe driver. The State has taken charge; a new political class has arisen and seized the vanguard to form a triumvirate with the Third Sector to persuade us what is in our best interests. Their managerial minions now set the agenda.

What is to be done...? (Vladimir Ilyich)

Downsize care by downsizing care expectations. Initiate a programme of ‘identifying’ the One Percent who statistically die via a protocol of assessment involving statistical probability and intuitive judgement and earmark them for EoLC.

This will (of course!) trawl in many who would not have formed part of that One Percent cohort. By far the greater part of medical error consists of medical misdiagnosis. There will be excess deaths...
The number of older adults is increasing 
• The absolute number of older adults and their proportion in the population is significantly increasing. From 1983–2008, the proportion of the total population aged 75 years and over in England increased by a third from 6% (2.9 million people) to 8% (4.0 million people). The population aged 75 and over is projected to increase to 7.2 million in 2033, and the number of people aged 90 and over is projected to increase from 0.4 million in 2008 to 1.2 million in 2033.(Office for National Statistics).
• Increases in the ‘oldest’ population have resulted from falling mortality rates in the second half of the 20th Century and increased birth rates at the beginning of the 20th Century (Dini & Goldring, 2008). In the UK, from 1968–2008 mortality rates declined by 51% in males and 43% in females (Office for National Statistics, 2009).
• In England, life expectancy (period expectation of life at birth) increased by over 6 years in males from 1980–82 to 2006–08, from 71.1 years to 77.7 years, and by over 4 years in females, from 77.0 years to 81.9 years (Office for National Statistics) 
National End of Life Care Intelligence Network
Mr. Patrick Gordon Walker’s landmark observations echo down the years...

There are always consequences. A programme or strategy promoted and rolled out by government will multiply those consequences. There have been "excess deaths". There are "missing" older adults. Where are those missing ninety year-olds?

A crisis programme of life limitation has been rolled out and implemented. It is the EoLC Strategy. It is still only 'half way there'. 

Yippee! More freed up beds. Keeping people alive is a costly business. We shall fill this pension black hole with the corpses and cadavers of those deemed old and useless and only making this black hole larger still.

We shall call this providing dignity and care and compassion!

The language of Newspeak is rife and the frail elderly are assessed according to the Lakhani Recommendations. These recommendations promote a policy of passive euthanasia through non-action. This is said to preserve ‘dignity’.

A pro-euthanasia group associated with The Voluntary Euthanasia Society Dignity in Dying has conned the Gambling Commission National Lottery to provide the funding and groomed Age UK to provide the means to sign up the frail elderly to contracts to deny them treatment. This is said to advocate their ‘rights’.


Keeping people alive is a costly business

The National Lottery has provided funding to a pro-death euthanasia group to 'advocate' for the rights of the vulnerable elderly. Shall it, then, provide funding to a pro-life group advocating for the rights of the unborn child?

The euthanasia lobby has found growing support on both sides of the House and in both Houses. This isn't just about 'dignity in dying'; it is about digging the economy out of the pensions and benefits black hole into which it is plunging by filling it with the corpses of the most frail and the most vulnerable members of the community.

Diagnosing dying and putting patients on a pathway sounds like death with dignity but it's going to save governments, and the taxpayers who fund them £Billions.

Of course it's not about killing people, but it's still cheaper to kill the seriously ill than to keep them alive in hospitals, nursing homes or hospices.

This isn't just about pensions and benefits. Hospitals under financial pressures and bound by targets don’t want bed-blockers clogging the wards eating up finite resources.


What is to be done...? (Vladimir Ilyich)

Ship them out...?


This is the Southern Daily Echo –
A FRAIL 88-year-old woman who is blind in one eye and vulnerable to falls was discharged from a Hampshire hospital – at 11.30pm.
Today a Hampshire MP has demanded answers after dementia sufferer Rose Sweetman was asked to take a taxi home late at night – despite having no cash on her.
Her 93-year-old husband Leonard, a Second World War veteran, was asked to arrange the journey home – even though he had been under the impression she was being kept in for the night.
Now he has hit out at the Royal Hampshire County Hospital over the care of his wife, even claiming staff had once sent her home “more or less stripped to the waist” in a taxi.
This is not exceptional or at all anomalous.

Pertinent reading -
Transportation belongs to the 19th century. These are not society's dregs; these are our venerable elders, those whom we should value!

Over the border, this is the Sunday Post –
Hundreds of failings in elderly care provided by Scotland's hospitals have still to be put right - nearly two years after many were first identified.
What is to be done...? (Vladimir Ilyich)
The fact the majority of failings identified by inspectors relate to dementia care was no surprise to Peter Tulloch.
The 56-year-old launched a legal action against the NHS last year amid claims his mum starved to death in an Edinburgh hospital. 
Jean Tulloch, 83, was given just one day’s calorie intake in the space of three weeks after being admitted for a urinary tract infection. While Jean’s death certificate officially listed “end-stage dementia” as killing her, she was on the controversial Liverpool Care Pathway (LCP) which Peter describes as the “starvation diet” and the certificate also notes her diet “materially contributed” to the former nurse’s death. 
Peter said: “These new figures are shocking but sadly they are not surprising. I have little confidence that lessons are being learned from these failings. 
“The hospital where my mother died, the Western General in Edinburgh, was inspected by HIS just two weeks after her death. They reported a shortage of beds, so in my mind it is not a coincidence that she was on the LCP.”
The Post fails to note that there is an ongoing Scottish EoLC programme to tackle this problem which sets out to downsize care expectations and collar the elderly for palliative care, reducing those hospital admissions, culling the elderly hospital population and the high cost of unsustainable, curative options - a veritable Scottish Mint! - AND tackling these 'failings' all in one fell swoop...
"What! all my pretty chickens and their dam
At one fell swoop?"
- Will Shakespeare (Macbeth: act IV, scene 3)
Further reading -
Liverpool Care Pathway - And Where Is Margherita...?
Liverpool Care Pathway - Fallen Unto Iniquity
What is to be done...? (Vladimir Ilyich)

The NCPC held an exclusive Subscribers Forum on Wednesday 19th March. The big names in attendance included Wee Beelong. We are at a crucial stage. We are at the halfway point -

2013/14 has been a crucial year for end of life care as well as NCPC & the Dying Matters coalition. It has marked the halfway point of the 10-year End of Life Care Strategy; NHS England has launched a process to “refresh” the strategy; we have had the report of Neuberger review of the Liverpool Care Pathway, as well as other landmark reports such as the Francis report; and the Government has said it will hold a review into the feasibility of a “national choice offer” to enable people to die at home.
Simon Chapman, Director for Public & Parliamentary Engagement at NCPC has spoken at the ICO Conference Centre on the LKP and 'what went wrong'.

The Director is expanding his empire.

NCPC/Dying Matters have recruited a Public & Parliamentary Engagement Manager -



NCPC/Dying Matters are recruiting a Public & Parliamentary Engagement Officer -




What is to be done...? (Vladimir Ilyich)

Expand the EoLC programme...

This is NHS Jobs advertising for a Band 6 Amber EoLC Facilitator -


It is not possible to identify with confidence and ‘diagnose’ dying, but...
The clinical facilitator will use their experience and expertise to influence and change practice in wards to improve end of life care, staff confidence to identify, assess, manage and implement best practice for patients whose recovery is uncertain. This will include developing and running education and training programmes for all staff, collecting data and measuring the effectiveness of the care bundle. The main focus will be working clinically with ward staff to ensure staff are competent to use the AMBER Care Bundle.
The arrogant will gain confidence and certainty they may do so!

Thy will be done...?

Sunday, 16 March 2014

Liverpool Care Pathway - The Voice In The Wilderness

Where have all the old folks gone, long time passing...?





Features of opiate toxicity 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).

Where have all the old folks gone, long time ago...?

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)
It’s been ‘snowing’ all over. Weaned on Barton's Wessex Guidelines and versed in non-verbal pain assessment the doting angels look at you - and interpret that non-verbal response accordingly.

Where have all the old folks gone...?

The pre-emptive prescribing of the LCP shares its origins with the GSF Surprise Question; they are both grounded in Barton methodology and the Barton Care Pathway trialed at Gosport...
On the basis of these sources of evidence, I have concluded that a practice of almost routine use of opiates before death had been followed in the care of patients of the Department of Medicine for Elderly People at Gosport hospital, and the attitude underlying this approach may be described in the words found in many clinical records – ‘please make comfortable’. It has not been possible to identify the origin of this practice, since evidence of it is found from as early as 1988. The practice almost certainly had shortened the lives of some patients, and it cannot be ruled out that a small number of these would otherwise have been eventually discharged from hospital alive.The suppressed report of the Barton Care Pathway
The practice "almost certainly had shortened the lives of some patients"...

Gone to EoLC, everyone...

There are always consequences. A practice rolled out as policy will multiply those consequences. The statisticians did not get it wrong. It is time for justice to be served. The medics and the politicians must be hauled before the courts to face their accusers.

From the BMJ archives, 19 May 2008, a strong and consistent voice warns in relation to this practice rolled out as policy -
"... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."
This voice is the voice of Gillian M Craig of the Medical Ethics Alliance. Her voice has warned, consistent and true, over the years.

This is Gillian M Craig on Pub Med, September 1994 –



This submission stirred some interest and debate to which the author responded with The Debate Continues

Her voice has been a voice in the wilderness. 

That original Pub Med article, 'On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far?', is more pertinent and relevant than ever and should be made required reading for those rolling out the EoLC programme...




Palliative medicine is a relatively new and growing specialty and the hospice movement is held in high esteem by the public. Some doctors, however, have reservations. There are dangers in grouping patients labelled 'terminal' in institutions, because diagnoses can be wrong. There is a risk that if all the staff in an institution are orientated towards death and dying and non intervention, treatable illness may be overlooked. Not everyone who is referred for terminal care proves to be terminally ill, and no physician should accept such a diagnosis without reviewing the evidence personally.
Certain policies that are practised in palliative medicine would be dangerous if applied without due care and thought. In particular the view that in the terminal phase of disease 'no form of artificial hydration or alimentation is undertaken, all measures not required for comfort are withdrawn, and no treatment-related toxicity is acceptable'. It is not uncommon for the elderly to be admitted to hospital in a seriously dehydrated condition, looking terminally ill. A treatment-orientated physician will rehydrate these patients energetically, often with dramatic results, in order to buy time in which to assess the situation carefully. A therapeutically inactive doctor would lose many patients for the sake of avoiding a drip. Two examples from my personal experience will illustrate this point.
Case 1
An elderly man was sent to hospital for terminal care with a diagnosis of carcinoma of the pancreas. He had indeed had a stent inserted at another hospital to relieve bilary obstruction due to tumour. However, his 'terminal' illness was due to a small stroke and uncontrolled diabetes mellitus. He recovered with insulin and intravenous rehydration and lived happily for several weeks more.
Case 2
An elderly man was admitted for terminal care but the geriatrician felt the diagnosis of cancer was not well established. The main problem was severe dehydration with ischaemic feet and severe pressure sores on the heels. With intravenous rehydration and intensive nursing he recovered and went home for 18 months.
It is important for the public to realise that most patients with terminal illness can continue to eat and drink as and when they wish. Only in the last days may they be too weak or tired to bother, in which case the lack of food and drink will not contribute to death. If dehydration develops under these circumstances it is a natural consequence of irreversible disease, and artificial hydration would not be appropriate.
Care has been downsized and those assessed for the one percent are earmarked for EoLC. The language of Newspeak is rife and the frail elderly are assessed according to the Lakhani Recommendations.

We are half way there...

The ‘one percent’ is not just a Death List; it is to be identified at an ‘early stage’ to sign up for ACP documents. This is an ongoing process of grooming to agree Advanced Directives and DNR plans. The document is a statement of what you can’t do, not what you can do; it is a charter of negative liberties.

EoLC Pathways typically withdraw treatments.

EoLC Pathways define artificial feeding and hydration as “treatment”.

Do you really want to be connected up to tubes...?

These issues are ‘sensitive’ ones and the groomer, also, requires appropriate grooming to advance them successfully.
Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team and documented carefully. - DNACPR Form 
Age UK volunteers are today being groomed trained to groom provide guidance to “vulnerable older people” to sign up for ACP documents.


To take a decision to sedate a person, without hydration, until he/she dies is a very dangerous policy medically, ethically and legally. No doctor's judgement is infallible when it comes to predicting how close a patient is to death. To say that it is a matter of days, and to treat by this method, is to make the prediction self-fulfilling. I know of a patient who died after at least seven days of sedation without hydration - how much longer would he have survived with hydration? Diagnostic errors can also occur. A reversible psychosis or confusional state can be mistaken for terminal delirium, aspiration pneumonia for tracheal obstruction, obstruction due to faecal impaction for something more sinister, and so on. The only way to ensure that life will not be shortened is to maintain hydration during sedation in all cases where inability to eat and drink is a direct consequence of sedation, unless the relatives request no further intervention, or the patient has made his/her wishes known to this effect. If naturally or artificially administered hydration and nutrition is withheld, the responsible medical staff must face the fact that prolonged sedation without hydration or nutrition will end in death, whatever the underlying pathology. Even a fit Bedu tribesman riding in the desert in cool weather, can only survive for seven days without food or water.

The judgement regarding hydration and nutrition in the Bland case was clearly swayed by the patient's irreversible brain damage, although the law as to killing is unaffected by the victim's mental state. It would be extremely dangerous to extrapolate the legal decision made in this case to other clinical situations. The legality or otherwise of withholding hydration and nutrition from the dying has not been tested in the courts in the United Kingdom. 
Despite the differences in mental state, pathology and life expectation between a terminally ill sedated patient and one with a persistent vegetative state, the key issues are similar. Are you, by withholding fluid and nourishment, withholding the means of sustaining life? In short are you killing the patient? The answer I fear in some cases could be YES. In some terminally ill patients, especially those who are rendered unable to swallow by heavy sedation, failure to hydrate and nourish artificially could be judged an unlawful omission. The question of intent is important and the principle of double effect, and other medico-legal issues are relevant. However, doctors who deliberately speed death could face the prospect of life imprisonment. Clearly the legality of prolonged sedation without hydration is highly debatable yet this treatment is regarded as ethical and compassionate by senior and respected specialists in palliative medicine. If a dying patient is treated in this way there may be reasonable grounds for doubt as to whether the patient died of the treatment or the disease. It is our duty and our privilege as doctors to sustain life, not to shorten it. Euthanasia must remain illegal, and practices that seem tantamount to euthanasia must be exposed.
The consensus in the hospice movement seems to be that rehydration and intravenous fluids are inappropriate in terminal care. Dehydration is even considered to be beneficial in patients with incontinence! This is a weak argument to justify withholding intravenous fluids. Therapeutic anuria may be the ultimate cure for incontinence but the side-effect is death. Those who have coped with incontinence without a catheter in the past can be nursed without a catheter to the end, if that is their wish. Rehydration should not influence this aspect of care. Hospice staff also argue that a drip makes it more difficult to turn a dying patient in bed, yet they are happy to give analgesics by subcutaneous infusion when necessary, and occasionally use a drip in patients with hypercalcaemia. To those of us who use drips frequently on acute medical, surgical and geriatric wards, these arguments do not carry much weight. Setting up a drip or a subcutaneous infusion is a simple and straightforward procedure that rarely causes the patient discomfort or distress. Many dehydrated patients look and feel a lot better when they are rehydrated. If the staff in hospices used drips more, they would not have to find so many reasons for avoiding them.
If hydration and nutrition are withheld, the attendant staff must be sensitive to the effect this may have on the family and friends. Some say that a patient should be comatose, so as not to experience thirst, before it is morally acceptable to withhold or withdraw intravenous fluids. It is widely assumed that a terminally ill patient is not troubled by hunger or thirst but this is difficult to substantiate as few people return from the grave to complain. Thirst may or may not bother the patient. Concern about thirst undoubtedly bothers relatives.
 
They will long to give their loved one a drink. They may sit by the bed furtively drinking cups of tea, taking care to make no sound lest the clink of china is torture to the patient. Anyone who has starved for hours before an anaesthetic will sympathise with dying patients who seem to thirst and starve for days. Nurses are taught that moistening the patient's mouth with a damp sponge is all that is necessary to prevent thirst. Relatives may not be convinced. It may well be that sedation relieves the sensation of hunger and thirst. If there is evidence to this effect it would be helpful for the relatives of dying patients to be told about it.
It has been said that the family must request no further medical procedures before treatment can be withheld and that the previously expressed wishes of the patient or current family must predominate over those of staff. Staff who believe strongly that intravenous fluids are inappropriate should not impose their views on knowledgeable or distressed relatives who request that a dying patient be given intravenous fluids to prevent dehydration or thirst. To overrule such a request is, in my view, ethically wrong. The only proviso would be if the patient had, when compos mentis, specifically said that he/she did not want a drip under any circumstances.
No relatives should be forced to watch a loved one die while medical staff insist on withholding hydration. This has happened to my knowledge. Such an experience is deeply disturbing and could haunt a person forever. Is all this agony worth it for the sake of avoiding a drip? I think not.
As Rabbi Lionel Blue said recently of theology: 'Even more important than your views is the kindness with which you hold them, and the courtesy with which you treat those who oppose you'. The same could be said of the issues explored in this paper. People who hold strong views in this difficult and emotive area of palliative medicine should hold them kindly and with sensitivity. At the end of the day there should not be the slightest grounds for suspicion that death was due to anything but the disease. Unless this can be guaranteed, the public's faith in doctors in general, and in the hospice movement in particular, will be ill founded.

Further reading -
Liverpool Care Pathway - The Perception Of Dying And The Perception Of the Dying

Liverpool Care Pathway - When The Prescription Is EoLC