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

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The only reason that tube feeding has been identified as a ‘treatment’ is so that it can be withdrawn or denied.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.


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.

"... 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. 


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

No comments:

Post a Comment