Liverpool Care Pathway – An Oft- Recurring Theme..?

From The Sunday Times - May 25, 2008

When Edna Purnell was referred for “gentle rehabilitation” at a local healthcare unit after a hip replacement operation, her family thought she would be given exercises to get her back on her feet and sent home after a fortnight.

Instead she was put to bed in a darkened room and put on a regime of morphine within a day of her arrival. Less than a month later she was dead.

From the NMC complaint letter - November 12, 2009

My elderly mother went into Caterham Dene, ostensibly, for two or three weeks respite care…

While at Caterham Dene, they would also look into the persistent back pain her GP had put down to a posture problem, a result of inactivity, but which a visiting nurse thought might be a hip problem…

On Friday [within a day of her arrival], they had moved her into a side room. She was, at best, described as confused, but she imparted to me that she didn’t like them there; those were her last coherent words to me in this life!

Her pain killer, prescribed for the back condition, had been replaced by morphine…

Within the space of just two days, she was reduced to a condition of complete unresponsiveness…

From the NMC complaint letter - February 01, 2011

They permitted my mother to present cyanosed on the Saturday and did nothing. I received a call early on Sunday morning to say she was suffering from heart failure and that they were getting the doctor. Still unaware of the reality of the situation, we thought they were actually getting the doctor at the hospital. No, they were calling Thamesdoc! An hour later, another call revealed that Thamesdoc were unavailable and so they had called an ambulance.

We were not aware, had not been informed, that this was a nurse-led hospital and that there was no medical doctor on site at the weekend. My mother had presented cyanose, been left to deteriorate to a catastrophic life-threatening condition - and they called Thamesdoc. My mother actually perished halfway between Caterham Dene and ESH, paramedics ramming tubes down her throat in frantic, vain attempts to revive her. This was reported to me in A & E in explanation of the very apparent bruising upon her.

 It is a duty incumbent upon every medical person to protect life and to do no harm. And yet, it is now plain to us that there is – or was - a policy set in place at Caterham Dene to make no great effort to intervene to preserve life, to ‘let them go’ and even to ‘help them on their way.’ That is why there was no effort at all by nursing staff, as is now admitted, to monitor my mother’s status. This was not as a result of a failure in the nursing procedure; they were following policy in not doing so, to permit nature to take its course and even lend it assistance!

Letters sent to the District Nurses Office to discover what had transpired were actually returned ‘refused’ by Royal Mail and the person to whom we had written and who had offered help transferred, or was transferred, elsewhere.

As is borne out by testimony of the correspondence documents, my mother was subjected to actual harm both by action and by inaction at crucial points in her treatment, or rather mistreatment. By negligence, incompetence, malpractice or by design, this did cause her to suffer and to perish at their hands. And if they have nothing to hide, why - counter to all commonly accepted standards and contrary to the sources which we have cited – do they persist in denying us this most basic and fundamental knowledge of the names of these persons at Caterham Dene to whose charge she entrusted her well-being – and her life?

Accordiing to PALS, this ‘policy set in place at Caterham Dene’ is the Liverpool Care Pathway.

Liverpool Care Pathway - By Any Name . . .

Euthanasia: More cause for concern

ICN and Scottish Catholic Observer carry the following worrying report -

Dr. Clare Walker,  president of the Catholic Medical Association, has declared that euthanasia is being widely practiced in the NHS.

One development that has enabled this to happen is the adoption of the Liverpool Care Pathway (LCP). Dr. Walker also believes the misuse of the LCP is leading to what, by any other name, is euthanasia.

The LCP is nationwide -

The scheme has now been rolled out across the country, its application depending on widely differing levels of ethical interpretation. “If it is used out of context, then it could be used to the detriment of patients," she says.

"A patient comes into a resuscitation bay and it is not always clear if a condition is acute and can be treated,” said Dr Walker, who recalls that in some hospitals the LCP has become known as the Lazarus Care Pathway due to the number of people who have been put on it inappropriately, are not moribound, and subsequently need to be actively treated.

A colleague of Dr Walker’s did a survey on the basis of crematorium records that found, in 23 per cent of all deaths of people in one city placed on the LCP, there had been no definite diagnosis at any stage.

Dr Walker says she is regularly contacted by distressed healthcare professionals and managers who describe their experience of witnessing repeated instances of unofficial, active euthanasia in their local areas. 

The LCP is going global -

The National LCP Office NZ was established in November 2008 to coordinate the sustainable implementation of the LCP in New Zealand.

The Australian Best Care of the Dying Network is seeking implementation of the Liverpool Integrated Care Pathway (LCP) into key health care settings within Queensland, ultimately expanding the network to include any health care setting in Australia expressing an interest in using the LCP.

Time to stand up and be counted:

Please register your opposition to this madness -

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Liverpool Care Pathway - The alternative To Euthanasia?

From the British Medical Journal

Dutch research reflects problems with the Liverpool care pathway

        Adrian J Treloar, consultant and senior lecturer in old age psychiatry

The Liverpool care pathway (LCP) is the UK’s main clinical pathway of continuous deep sedation and is promoted for roll out across the NHS. ¹Rietjens et al’s study highlights some serious weaknesses in its design.

The eligibility criteria do not ensure that only people who are about to die are allowed on to the pathway. They allow people who are thought to be dying, are bed bound, and are unable …

The four LCP ‘triggers’ -

l        Bed – bound.

l        Only able to take sips of fluids.

l        Semi – comatose.

l        No longer able to take tablets.

According to Adam Brimelow, BBC News health correspondent, there is evidence that some clinicians may already be using continuous deep sedation (CDS), as a form of "slow euthanasia".

Research suggests use of CDS in Britain is particularly high - accounting for about one in six of all deaths.

It seems that there's substitution from the practice of euthanasia to the practice of continuous deep sedation  Dr Judith Rietjens Erasmus University Medical Centre in Rotterdam

Every year more than 1,000 people are admitted onto the wards at St Christopher's Hospice in Sydenham, south London.

It is at the forefront of research and education in end-of-life palliative care.

Dr Nigel Sykes, medical director, said CDS can be appropriate for patients who become confused and deeply agitated - but only when nothing else can relieve their distress.

But research by Clive Seale, professor of medical sociology at Bart's and the London School of Medicine and Dentistry, suggests the use of CDS across the UK is far from "uncommon".

"The only other two countries where the prevalence has been measured is in the Netherlands and Belgium," said Professor Seale.

"The surprising thing was that in the UK the prevalence of continuous deep sedation until death was very high indeed, 16.5% of all UK deaths."

That is twice as high as in Belgium and the Netherlands.

But while rates of CDS in the Netherlands appear to be rising, the use of euthanasia has declined.

Cancer patients

Dr Judith Rietjens, from Erasmus University Medical Centre in Rotterdam, said this shift is particularly marked among GPs looking after cancer patients.

"It seems that there's substitution from the practice of euthanasia to the practice of continuous deep sedation," she said.

"We can see in our study that those sub-groups where we saw an increase of continuous deep sedation - just in those sub-groups - we saw a lowering of the frequency of euthanasia."

Professor Seale thinks something similar may be happening in the UK.

"There is good evidence from the Netherlands and Belgium to show that quite a lot of doctors who find providing euthanasia very emotionally distressing and ethically difficult, find that providing continuous deep sedation is an easier thing to do," he said.

"In those countries euthanasia is an option - it's legal. In the UK it isn't.

"Whether doctors in the UK are thinking in this way, and nurses as well, is something which is worth exploring more."

There are fears that CDS is being used inappropriately.

Father's death

Dr Philip Harrison, a GP now based in New Zealand, set out his concerns recently in the British Medical Journal, following the death of his father in Doncaster Royal Infirmary.

He was put under continuous deep sedation without being consulted, and so had no chance to say goodbye to his family.

Dr Harrison reached the hospital two hours before his father died.

It was as near to a form of murder that I had come across,  Dr Philip Harrison GP

"I'm 100% certain he would have been horrified to know that he would never see us even though we were coming," he said.

"There was no reason on earth why he would have wished to have been put to sleep, unless he was obviously distressed or agitated or in pain.

"But there was no evidence he was in pain at any stage during his admission."

Dr Harrison, who has long experience in palliative care, decided not to sue the trust - but he did try to get reassurance that it couldn't happen again.

Despite an apology he is still not satisfied.

"I don't know what the legal term is but to me it was as near to a form of murder that I had come across," he said.

"I have never seen that in my medical practice before. I've seen euthanasia once, but I've never seen anybody being put to death without consent."

Dr Harrison said he is concerned about what could be going on across the NHS in the name of caring and terminal sedation. The truth is, no one knows.

Liverpool Care Pathway – The Unthinkable Policy

What was the unthinkable...

“Police are reported to be investigating 60 cases involving pensioners who died after allegedly being deprived of food and water by hospital staff.”

Is still the unthinkable...

“…the CQC expressed "major concerns" about the failure to ensure elderly patients had enough to eat and drink.”

But is become the policy...  

Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong. As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients."

Liverpool Care Pathway – The Truth Is Out There

 The Care Pathway

"Under the scheme, doctors and nurses collectively agree that there is no possibility of recovery. They then remove beneficial medicines and invasive medication, such as intravenous drips. They may also sedate the patients and withhold food and drink."

 Mike Richards, who was involved in the introduction of the Liverpool Care Pathway, said it was "essential" that medical staff were skilled in deciding who should be put on the scheme for those at the end of their lives.
It follows concerns that patients with terminal illnesses are being made to die prematurely because they are incorrectly placed on the pathway, which can mean the withdrawal of food and fluids.

On September 2009, six palliative care experts wrote to a national newspaper saying that prediction of death is an inexact science and that decisions are made under the Pathway “without regard to the fact that the diagnosis could be wrong.”  They stated that the LCP results in some patients dying prematurely and that a “national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients."

***      ***      ***

1999

NHS euthanasia claims 'ludicrous'

The NHS is accused of "involuntary euthanasia"

A senior consultant's claim that elderly patients are being left to starve to death in NHS hospitals has been dismissed by Health Secretary Alan Miburn as "ludicrous". 

Dr Adrian Treloar, a consultant in old age psychiatry and senior lecturer in geriatrics at the Greenwich Hospital and Guys', King's and St Thomas's Hospitals in London, said there was an unofficial policy of "involuntary euthanasia".

He said patients were being denied appropriate treatment partly because of the huge pressures on beds building up in the health service. 

Dr. Adrian Treloar claims the elderly
do not always get proper care.

Police are reported to be investigating 60 cases involving pensioners who died after allegedly being deprived of food and water by hospital staff.

Detectives in Derbyshire have filed a report, said to run into several thousand pages, to the Crown Prosecution Service, after a 22-month inquiry at the Kingsway Hospital in Derby. 

The investigation is understood to centre on the deaths of around 30 elderly patients. 

A pressure group formed by relatives, SOS NHS Patients in Danger, is considering taking the issue to the European Court of Human Rights. 

But, speaking on the Today programme on Wednesday, Mr Milburn said: "If the allegation is that the NHS is routinely starving elderly people to make more room in hospitals it is simply untrue, it is ludicrous, it is scaremongering. 

"Frankly, it is also an attack on the integrity of doctors and nurses who spend most of their working day caring for elderly patients." 

It is very clear that the elderly do not always get all the care they need

Dr Adrian Treloar

Dr Treloar told the BBC on Tuesday: "It is very clear that the elderly do not always get all the care they need."

He was also quoted in an interview with the Daily Telegraph as saying "there may be a tendency" to limit care for the elderly who are very seriously ill to relieve severe pressure on NHS beds. 

He claimed that old people who start to resist early 

discharge are seen as "an encumbrance". 

Dr Treloar said he had heard many allegations from families of relatives being denied treatment and left to die in NHS wards. 

BMA guidelines 

Dr Michael Wilks said the guidance was drawn up to end confusion

Recent British Medical Association (BMA) guidelines say doctors should be allowed to authorise withdrawal of food and water by tube for victims of severe stroke and dementia who can no longer express their wishes. 

The guidance says: "Doctors should have the final say over whether treatment including feeding and giving water is in the patient's best interest. It is not always appropriate to prolong life." 

Dr Michael Wilks, chairman of the BMA's ethics committee, said the guidelines were drawn up because of widespread confusion among doctors about what was acceptable practice. 

"We tried to help doctors work through a clinical framework, working out whether the particular treatment - which might include artificial nutrition and hydration - was in fact of benefit to the patient. 

"When you have a treatment that is of no further benefit you have an ethical responsibility to at least consider withdrawing it." 

Dr Wilks said it still unacceptable for doctors to withdraw treatment specifically to kill patients. 

Call for government action 

The charity for the elderly, Age Concern, demanded urgent government action and accused the NHS of adopting a culture of ageism and rampant discrimination. 

Sally Greengross, Age Concern director general, said: "We have been contacted by thousands of people who have complained about the treatment of the elderly in the NHS system. 

"What this senior consultant has said links very closely with our own findings. We need urgent legislation to prevent this discrimination." 

***      ***      ***

The Care Pathway

"Under the scheme, doctors and nurses collectively agree that there is no possibility of recovery. They then remove beneficial medicines and invasive medication, such as intravenous drips. They may also sedate the patients and withhold food and drink."

Mike Richards, who was involved in the introduction of the Liverpool Care Pathway, said it was "essential" that medical staff were skilled in deciding who should be put on the scheme for those at the end of their lives.

It follows concerns that patients with terminal illnesses are being made to die prematurely because they are incorrectly placed on the pathway, which can mean the withdrawal of food and fluids.

On September 2009, six palliative care experts wrote to a national newspaper saying that prediction of death is an inexact science and that decisions are made under the Pathway “without regard to the fact that the diagnosis could be wrong.”  They stated that the LCP results in some patients dying prematurely and that a “national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients."

***      ***      ***

2011

Hospital patients 'left so thirsty doctors had to prescribe water'

Shortage of money is not the problem, but a failure to look beyond a patient's clinical needs, says the NHS Ombudsman

By Jeremy Laurance, Health Editor

Thursday, 26 May 2011

Doctors caring for elderly patients in hospital are being forced to prescribe water for them in order to ensure they have enough to drink.

Inspectors from the Care Quality Commission (CQC), the NHS watchdog, found nurses sometimes left patients so thirsty that the only way for doctors to ensure they had enough liquid was to add "drinking water" to hospital medication charts.

The revelation comes in the first reports from the CQC into dignity and nutrition of elderly people treated by the NHS, which reveals a failure to attend to the most basic requirements of care. The Health Secretary, Andrew Lansley, who ordered the reports, said the failings were "unacceptable".

Of the first 12 NHS trusts inspected, three failed to meet the essential standards required by law of respecting and involving people in their care and meeting their nutritional needs. Less serious concerns were identified in three further hospitals, giving a 50 per cent overall failure rate. The reports are the first of 100 inspections carried out, which are continuing. They follow a decade of investigations that have revealed an NHS riddled with ageist attitudes, in which elderly patients are neglected, poorly treated and marginalised. Shortage of money and resources is not the problem but rather, as the NHS Ombudsman said in a scathing report last February, an "ignominious failure" to look beyond a patient's clinical condition and respond to their social and emotional needs. A spokesman for the CQC said the 50 per cent failure rate was likely to be reflected nationally.

The worst offender was Alexandra hospital, Redditch, Worcester, where the CQC expressed "major concerns" about the failure to ensure elderly patients had enough to eat and drink. The Royal Free hospital in London and Ipswich hospital also failed to meet the standards required by law.

At Alexandra hospital, inspectors saw meals being served to patients who were asleep. Trays were left out of reach, patients were not offered help to cut up their 

food and one patient was seen trying to tear a tomato apart with their fingers. Nobody was routinely offered handwashing before or after eating. Although the trust said it offered a choice of dishes, one patient who declined a meal had it taken away without being offered any alternative.

Medical staff explained how they prescribed drinking water on medication charts "to ensure people get regular drinks". Inspectors saw examples of this being done and were told it "worked". Ward staff said they were aware of drinking water being prescribed and that this was done to "make sure people get enough fluids".

The reports on the 12 trusts also highlight how patients were not weighed, making it impossible to check if they were losing weight. Malnutrition is a major problem among elderly patients, affecting 185,000 discharged from hospitals in England in 2008-09, and the problem is rising.

Others were not treated with dignity, involved in their own care or were spoken to in a condescending manner. One man said hospital staff talked to him "as if I'm daft".

Mr Lansley said: "The inspection teams have seen some exemplary care, but some hospitals are not even getting the basics right. That is unacceptable."

***      ***      ***

The Care Pathway

"Under the scheme, doctors and nurses collectively agree that there is no possibility of recovery. They then remove beneficial medicines and invasive medication, such as intravenous drips. They may also sedate the patients and withhold food and drink."

Mike Richards, who was involved in the introduction of the Liverpool Care Pathway, said it was "essential" that medical staff were skilled in deciding who should be put on the scheme for those at the end of their lives.

It follows concerns that patients with terminal illnesses are being made to die prematurely because they are incorrectly placed on the pathway, which can mean the withdrawal of food and fluids.

On September 2009, six palliative care experts wrote to a national newspaper saying that prediction of death is an inexact science and that decisions are made under the Pathway “without regard to the fact that the diagnosis could be wrong.”  They stated that the LCP results in some patients dying prematurely and that a “national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients."

***      ***      ***

Liverpool Care Pathway - A Grave And Perilous Pathway

The Department of Health (DOH) uses a Commissioning for Quality and Innovation (CQUIN) payment framework which enables commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals:

"It makes a small proportion of provider income (0.5% of contract value in 2009/10) conditional on achievement of locally agreed goals around quality improvement and innovation. It is intended that goals should be stretching but realistic."

CQUIN has set targets for 2011/2012 with regard to the End of Life program.

The forward plan is to increase the number of patients identified to be on the end of life care pathway and from a baseline of 0% to 20%; it is further planned to have 30% of all patients who die in hospital dying on the Liverpool Care Pathway.

To ensure they receive their provider income in fulll, Trusts have to comply with or exceed these goals. Some, like Royal Brompton, have upped the plan expectations:

1) 95% of patients identified as end of life (last 48 hours of life for expected deaths) are offered an EOL care planning discussion
2) 80% of patients offered a discussion should have an advanced care plan
3) 98% of patients who have an advanced care plan should have a record of the decision to resuscitate stated clearly in the notes
4) 50% of patients who die in hospital (expected deaths) should die on a Liverpool care pathway 

It is the DOH which is the driving force behind rolling out LCP across the NHS!

From 'cradle to grave' was the promise. Cradle to grave has become a bit of a stretch with the pressure of the financial constraints involved. (It's that bit in-between that's the problem!)

Putting pressure on clinicians to identify patients as 'dying' to place them on LCP simply to achieve these DOH targets is fraught with peril! Clinicians will be hounded, against their better judgement, by cash-strapped Trust's business and finance managers to meet targets in order to sustain funding.

A 'high quality' life cannot be guaranteed but, by golly, they're going to make darned sure we all get a 'high quality' death!

Liverpool Care Pathway - The 'Lazarus' Care Pathway

The following article is published on

Clerical Whispers  and CN Cath News

Euthanasia 'unofficially' practised in UK, says leading 

Cath doctor

The president of the Catholic Medical Association in the UK believes that euthanasia is quite widely practised in the country's National Health Service in an unofficial way, said a report in the Independent Catholic News.

Dr Clare Walker explained how she is regularly contacted by distressed health care professionals and managers who describe their experience of witnessing repeated instances of unofficial, active euthanasia in their local areas.

"The standards of medical ethics and of interpretation of existing legislation appear to vary greatly around the country and from one organisation to the next, even in the same local area," said Dr Walker.

One development that has enabled this to happen is the adoption of the Liverpool Care Pathway (LCP), developed in Liverpool in the 1990s as a result of collaboration between the Royal Liverpool Hospital and the Marie Curie hospice.

It aimed to bring hospice-style palliative care for those living out their last hours in hospital and its main emphasis was to unite professional support in the fields of physical treatment, psychological support, and support for carers and spiritual care.

"There is no reason to be suspicious when the LCP is being used in appropriate circumstances to a higher standard of care," said Dr Walker.

However, the scheme has now been rolled out across the country, with the application depending on widely differing levels of ethical application.

"If it is used out of context, then it could be used to the detriment of patients. For example, a patient comes into a resuscitation bay and it is not always clear if a condition is acute and can be treated," said Dr Walker, who recalls that in some hospitals the LCP has become known as the Lazarus Care Pathway due to the number of people who have been put on it inappropriately, are not moribound and subsequently need to be actively treated.

Liverpool Care Pathway - Time To Stand Up And Be Counted

"It is not the function of the government to keep the citizen from falling into error; it is the function of the citizen to keep the government from falling into error." 

---- U.S. Supreme Court Justice Robert H. Jackson

In lending its support to the spread of the Liverpool Care Pathway across this land and globally, our government has fallen into error. It is time to stand up and be counted.

Every patient is an individual and every patient is an individual case. Whatever ‘signs’ the LCP defines as being an indication of approaching and encroaching death, none of these ‘signs’ are so atypical that they can be excluded from being due to any other cause.

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 LCP expects of the clinician is difficult, therefore, and fraught with peril.

Mum had experienced annoying respiratory tract secretions (RTS) for some four years and more which her GPs had failed to treat adequately or at all. This bothersome catarrh would sit at the back of her throat and she would treat it herself with proprietary medicines and home-made remedies that were no less effective than those supplied by her GPs and which, certainly, did her no harm. That cannot be said of the appliance one doctor prescribed for her!

A steroid nasal inhaler was supplied to her by Dr gg . This only succeeded in producing a severe reaction. That night, mum was awoken with what she described as a ‘banging’ in her head and accompanying dizziness and distress, and no relief whatsoever from the catarrhal condition. She became nauseous and actually thought her last hour had come.

For some reason, the GP took my mother’s report of the incident personally, as though any criticism of the prescribed treatment was a personal criticism of him. Instead of reporting the adverse side-effect as is advised in the BNF, Dr gg  blatantly denied any connection of cause and effect. However, it was later suggested by Dr gggg  that it may have been the case that there had been a reaction to the steroid content of the inhaler.

The Liverpool Care Pathway, as stated in Liverpool Care Pathway - A One-Way Street Of No Return, requires that two of the following ‘signs’ are looked for -

- The patient is bed bound

- The patient is semi-comatose

- The patient is only able to take sips of fluid

- The patient is no longer able to take tablets

Well, let’s see now -

- Mum was bed bound

Over a period of some two weeks and more, my mother had become confined to bed for the reason that she could no longer face the steep stairs up to her bedroom. The stairs up and down each day had become a formidable ordeal, a hurdle and barrier in her daily life. Her GP, Dr g , had himself remarked upon how steep they were and so it was not just a matter of the frailty of a lady of elderly years. This confinement had physically wasted her legs. Mum had intended sleeping downstairs as a temporary measure, but she had been advised against this. Thus it was that the medical advice served no useful purpose except to create the predicament in which she found herself.

- Mum was semi-comatose

Mum was of an age at which she would spend many pleasant hours happily dozing in her chair at home, and did so in her bedroom where she was confined. But she had had all her medication withdrawn, without anyone's knowledge; her hearing aid had been damaged by person or persons unknown; and she was ‘morphed’ into a condition of utter insensibility; reduced to the condition of a virtual vegetable. Her last words to me in this world haunt me to this day, that she didn’t like them in there!

And she was old. Alas, a prime candidate for the pathway . . !

Please register your opposition to this madness -

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