Liverpool Care pathway – The Affordable Alternative

Free up beds, free up resources.

The cost of a good death is cost-able, determinable and finite; the cost of a good life..? Can the NHS afford to keep you alive?

Can the NHS afford to keep you alive?

Celebrities including the author Sir Terry Pratchett and the actor Sir Patrick Stewart have backed a campaign to allow terminally ill patients to receive help to die.

But a new poll found 70 per cent of disabled people were concerned that such a reform would create pressure on vulnerable patients to “end their lives prematurely”.

The survey for Scope, the leading disability charity, also found 3 per cent of the 500 disabled people questioned in the ComRes poll feared that they would personally come under pressure to commit suicide if the law were changed.

That pressure is real. In the Netherlands, the old carry cards to say they don’t want to be euthanized.

Every Day A Bonus

In the Telegraph, Charlie Cowper-Johnson is quoted as saying: 'While there's life I have hope, but euthanasia is the slippery slope'


“There were times, initially, that I thought ending my life was best for everyone. But now I realise that time and life are so very precious. That there are so many good things in life.”

IF Charlie Cowper-Johnson survives for another month - and he is confident that he will - he will be living on borrowed time. In October 1999, just two weeks after his wedding, he was diagnosed with motor neurone disease and given two years to live.

Life for Mr Cowper-Johnson, however, is precious. Unlike Diane Pretty, a fellow sufferer who, last week, was granted a High Court hearing for the right to be helped to die, he intends to fight for every moment.

He fears, however, that the ruling may eventually lead to the right to euthanasia - to which he is vehemently opposed.

Mr Cowper-Johnson said yesterday: "What time I have left is a gift. I stay confident that one day, I pray in my lifetime, a cure for this terrible terminal illness that traps an alert mind in a powerless body will be found.

"Can you imagine what a slippery slope last week's legal ruling could lead to? It would be open to all sorts of abuse by people who wanted to end their spouse's life.”

A slip of the tongue by a spouse or a relative on how they would struggle to cope with the burden of care would also be sufficient to mark a victim for withdrawal of treatments.

The advent of the introduction of LCP has made that all the more easy and certain.

How much is a good life? LCP has proven itself to be an affordable, less problematic alternative.

Liverpool Care Pathway - A Time To Stand Up And Be Counted

NHS - A National-socialist Health Service..?

Complacency permits the unthinkable to become thinkable and possible.


Register your opposition here:              care2

Liverpool Care Pathway - A Time To Stand Up And Be Counted

NHS - A National-socialist Health Service..?

Complacency permits the unthinkable to become thinkable and possible.


Register your opposition here:     Change.org

Liverpool Care Pathway - A Time To Stand Up And Be Counted

NHS - A National-socialist Health Service..?


Complacency permits the unthinkable to become thinkable and possible.




Register your opposition here:        GoPetition

Liverpool Care Pathway - A Forward-Planning Document For Dying As An Accepted And Acceptable Policy For Incorporation Into A Strategy And Stratagem Of Planned Financial Constraint In the Non-Hospice Setting

It should be apparent that the prominence being given to the Liverpool Care Pathway and its emplacement across the NHS is part of a deliberate campaign to soften up the British public to accept death as a valid life-choice; to prefer a ‘quality’ death to a life deemed or adjudged to lack or be lacking in quality.

In a cash-strapped NHS, where hospitals are being closed and elder abuse is on the rise, there is growing prejudice against the chronically ill and disabled who are seen as disproportionate consumers of limited resources. The LCP is a legalised death-choice instigated at the discretion of those that society has always understood were there to maintain and preserve life-choices. This is a sinister about-turn that places vulnerable lives at risk and actually raises great cause for concern.

It is already the Dutch experience that the controversy surrounding euthanasia may be side-stepped by the practice of CDS. Statistics now show this to be the case in the Netherlands. We should not be placing before health providers in Great Britain the temptation to consider aiding dying as a therapeutic option to be used in the patients' "best interests".

As is borne out by the outrageous opinions expressed by Baroness Warnock, there is growing prejudice against the chronically ill and disabled. Such outbursts are sure to become more commonplace as government financial restraints become more and more stringent. Such outbursts are sure to be given greater acceptance and receive greater approval as a valid stance to adopt, made respectable by those ensconced in respected positions in society.

With the introduction of LCP, killing has become a ‘legal’ therapy!

LCP provides a ‘controlled’ dying environment; it is ‘death by induction’ at the end of life, much as the controlled environment provided by induction at the beginning.

Clinicians, practitioners are being encouraged to proactively look for ‘signs’ of death. It will become not merely the policy of choice but, with implementation being proactively encouraged by the DOH funding policies, one of necessity, an obligatory requirement placed upon clinicians to adopt.

CQUIN is the DOH funding policy. CQUIN has set targets for 2011/2012 with regard to the End of Life LCP program. The forward plan is to increase the number of patients identified to be on the end of life care pathway 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 full, 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, especially now with the pressure of financial constraints being imposed. 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.

The Pathway is established as a legal "therapy" and, through DOH CQUIN payments, has been made the subject of cost/benefit assessment by health managers and economists. And in a cost conscious health service £5 for a lethal injection will be a tempting therapeutic option to £500 per week for effective palliative care.

The ‘legalised’ killing provided by LCP puts vulnerable people - the elderly, chronically sick, disabled - at risk. These people are already a financial or emotional burden on relatives, carers or society and this is why they need strong legal protection. This sinister about-turn that has taken place makes the unthinkable thinkable and possible.

The "right" to die a dignified death has replaced the right to live a dignified life and can so easily become a coercive offer, a duty to die. Vulnerable people are being placed at risk.

Rogue doctors such as Dr Harold Shipman are going to have a field day!

A Death Pathway is not needed in this country. Instead, we need the excellent palliative care already available to be made much more widely accessible. What is needed is a protocol for life to provide life with dignity up to the last moment of life.

The lingering question is pursed upon all our lips: 

Can the NHS afford to keep you alive?

Liverpool Care Pathway - Full Disclosure

From the British Medical Journal

End of Life Care


Gregory T Gardner, GP Principal
Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR

As a non specialist I contribute to this debate with hesitancy. Nevertheless, in spite of the laudable aims of the Liverpool Care Pathway to manage symptoms in the terminally ill and to stop all futile measures, I agree with Adrian Treloar and Mary Kiely that assessment of hydration is an important omission.

For some terminally ill patients dehydration may exacerbate other symptoms such as agitation or confusion. Correction of dehydration by the use of subcutaneous fluids may in some patients be helpful.1

The use of terminal sedation in the absence of proper assessment and correction of dehydration is bad medicine and at its worst (as in Holland) can be a substitute for euthanasia.

1 Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient? Support Care Cancer 1997;5:205-11.

Competing interests: None declared

Assessing dying

Bruno Bubna-Kasteliz, Professional Adviser

Office of Health Ombudsman, Millbank, London W1P 4QP

With 30 years' experience as a geriatrician, I always found it difficult to predict death, which is what is being sought here, in order to implement the LCP appropriately. While the LPC offers useful guidelines on the management of end-of-life symptoms, it seems to be rushing in with sedation and opiates without considering whether hydration and nutrition are also still valid treatment.

Competing interests: None declared


The role of the media in health care design

Joseph Kayalackakom Chandy (BSc, MBBS, DCH, DFFP), GP

Hugo Minney (PhD)

Shinwell Medical Practice, Horden SR8 4LE

Dear editor

The public, patients and carers need to be involved in the design of healthcare, and the involvement of national newspapers[1] in discussing the Liverpool Care Pathway (Palliative Care Guidelines) is to be welcomed.

However reasonableness doesn’t sell newspapers. Prof Millard’s letter to Daily Telegraph[2] is a case in point. Half-truths and non-sequiturs are presented as a cogent argument, and one has to wonder what point the group of authors are trying to make – is it that their unquestioned authority is under threat?

Let’s debate this pathway with full disclosure – what happened beforehand, what merits this new pathway brings, and what are the inherent risks. Let’s recognise that everyone should have an equal point of view, that doctors and nurses aren’t the ones dying or losing a loved one. But let’s above all be honest. Sincerely

REFERENCES

1 “Briefing: Fatal Decisions” by Helen Brooks; Sunday Times 6 Sept 2009 accessible at http://www.timesonline.co.uk/tol/life_and_style/health/artic le6823241.ece

2 “Dying Patients” by PH Millard, Anthony Cole, Peter Hargreaves, David Hill, Elizabeth Negus and Dowager Lady Salisbury; eletters Daily telegraph 3 Sept 2009 accessible at http://www.telegraph.co.uk/comment/letters/6133157/Dying- patients.html

Competing interests: None declared

“Let’s debate this pathway with full disclosure.”

“Half-truths and non-sequiturs are presented as a cogent argument, and one has to wonder what point the group of authors are trying to make – is it that their unquestioned authority is under threat?”

No, it is the clinicians in the hospital setting practicing the LCP who are behaving as if “their unquestioned authority is under threat” and denying full disclosure!

Laws have been set in place to permit doctors a God-given right of ownership of the patient’s decision-making capacity. Family and loved ones have actually been threatened not to intervene.

Families have had to fight, tooth and nail, to release their loved ones from the Death Pathway. This family pursued a case for three and a half years before it even being disclosed that the LCP was in place at Caterham Dene Hospital where my mother’s life was taken!

Yes, indeed, doctors and nurses aren’t the ones dying or losing a loved one. And let’s, above all, be honest! It is all too often the case that our loved ones aren’t even ‘dying’ but are only deemed to be by the Death Panel which takes the decision to place the patient on the Pathway! 

Liverpool Care Pathway - A Slippery Slope, Indeed

It has been said that we are on the threshold of a slippery slope.

Under the banner headline, Legal assisted suicide creates 'slippery slope' to doctors killing without consent, expert claims
Martin Beckford writes,

Prof David Jones said that if society agrees that it is in some people’s interests for them to end their own lives, it is difficult to resist the logical conclusion that others should be helped to die even if they have not made such a request.

He claimed this situation already exists in the Netherlands, where voluntary euthanasia is legal but where about 500 patients are also killed a year by their doctors without requesting to die.

Clinician-assisted suicide has been in place for decades.

Prof Jones, director of the centre for bioethics at St Mary’s University College, Twickenham, said: “My view is that it will lead from people who have asked to die, to people who cannot ask.”

Dr Howard Martin, the retired GP who

admitted hastening the deaths of patients

The issue of physician-assisted suicide or euthanasia has been highlighted recently after a retired GP, Dr Howard Martin, admitted to The Daily Telegraph that he had hastened the deaths of many patients including some who had not given their consent.

Police first investigated him in 2000 after complaints from nurses at the charity Macmillan Cancer Support. He remained suspended after his acquittal while police and a coroner looked into the deaths of dozens of other patients in case sufficient evidence could be found for fresh charges.

Dr Martin, who believes that about half of all doctors give injections to those who are about to die, said he felt no guilt or remorse.

Dr Martin was investigated over a total of “30 or 40” deaths. 

Dr. Shipman, Britain’s most prolific serial killer, with an estimated 258 victims, once briefly worked as a locum at Dr Martin’s practice.

The Telegraph quotes author, broadcaster and columnist, Gerald Warner that The Liverpool Care Pathway may be the slippery slope to backdoor euthanasia.

“Could the most ardent fan of George Orwell have asked for a more classic, totalitarian euphemism than "the Liverpool Care Pathway"? That is the technical term employed by the NHS for a system of patient assessment that selects those deemed "close to death" for withdrawal of food and fluids or being placed on continuous sedation until they die.”

Liverpool Care Pathway: Not Nice

The NICE ‘end of life care for adults’ quality standards concern adults approaching the end of life. They are not intended specifically for the old but the old, by definition, are already ‘adults approaching the end of life’.

An article in the Glasgow Sunday Herald uncovered almost routine starvation in Scottish aged-care facilities and estimated that up to 50,000 patients were dying in that manner in British public hospitals each year.  Glasgow Sunday Herald, July 2010)

There is scant regard for their dignity in living; perhaps, all that there is left is dignity in dying…

The old will be scooped up in the net whether they are actually nearing the end of their lives or not. My mother was, thus, ‘scooped up’.

Step By Step…

Dignity in Dying only supports assisted dying if it is the patient's informed choice.

She did not so choose, but was chosen – selected for induction upon the Pathway.

Her opinion could not be respected; she could not be trusted to ‘make an informed choice’ 

…and just to ensure that she was deprived of that choice, her hearing aid was mysteriously damaged and she was doped into a condition of servile stupefaction!

By Step…

According to the Bible, there are twelve Commandments; according to Dying With Dignity, there are twelve Principles of Law Reform.

Her meds were all withdrawn – without her knowledge and without ours.

They said she ‘refused’ hydration but ‘consented’ to morphine.

In what manner she refused and in what manner she gave consent I cannot imagine. Her hearing aid was put out of action; she was doped into a stupor: how could she make her choices known?

They are well-versed in ‘interpreting’ what is the patient’s unvoiced intention…

By Step…

However my mother made her ‘choices’ known, they conveniently fell in well with the LCP protocols of hydration-withdrawal and instituting a pre-emptive morphine regime. 

The sixth Commandment states: Thou shalt not kill

The sixth Principle states: A request for euthanasia must be made freely, voluntarily and without duress and must be clearly expressed.

Are not alarm bells ringing?

By Step, By Step…

Baroness Warnock: Old people with dementia have a duty to die and should be pushed towards death.

 “If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service.”

It is impossible to doubt that there are living people to whom death would be a release, and whose death would simultaneously free society and the state from carrying a burden which serves    no conceivable purpose... - Permitting the Destruction of Unworthy Life’ - Rudolf Binding and Alfred Hoche (1920) [Trans. Walter E. Wright. Issues in Law and Medicine 1994] p.246

The old are old; they’ve had their innings. If they won’t move aside, they must be moved aside – May Lady Warnock’s words translate as:

Old people who are a burden have a duty to die and should be pushed towards death…?

By Step

As:

Those who are a burden have a duty to die and should be pushed towards death…?

Step by certain step, it is a slippery slope we tread.

Step By Step

My mother was not even afforded a dignified death.

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 person.

Not NICE!

Liverpool Care Pathway - The Predictive Check-box

Pre-emptive prescribing

Here is James LeFanu, writing in The Telegraph:


“It is one thing to discontinue an intravenous infusion when the end is imminent; quite another to restrict fluids based on a prediction of how much longer a patient has to live.”

The correlation to draw from this statement is that it is unsafe to withdraw an intervention solely on the basis of a prognostic forecast. Prediction is always a hit and miss affair, as any astrologer will tell you!

Then, how unsafe must it be to proceed with an intervention on the same basis? And yet that is precisely what LCP recommends – ‘to Avoid Delay & Crisis’ by prescribing, even in the absence of the symptom, to pre-empt the predicted appearance of the symptom!*

*(End of Life Care - Symptom Control documents from NHS Milton Keynes)

Whilst it might be argued that an intravenous infusion is a medical intervention, ordinarily speaking, food and fluids are not an ‘intervention’ but a matter of essential life-maintenance.

The tragic logic of this statement is illustrated in the case in question which James LeFanu cites as has already been reported here.

Conversely, it is the case that our old ones, unable to feed themselves, have been left to starve. Baroness Warnock has said that elderly people suffering from dementia are “wasting people’s lives” and “wasting the resources of the National Health Service” and should be allowed to die. It could be argued that Lady Warnock’s comments, which were published in an interview with the magazine of the Church of Scotland, Life and Work, might spread a broader net to cover those not merely feeble of mind but frail of body. The old are old dodgers and old and past it in any case! There is a cruel logic to that, also.

Notwithstanding that it has been admitted that there is a lack and a scarcity of evidence with regard to the denial of hydration and feeding 

to its victims, the LCP protocol is that this shall be done in any case.

Yet, if there is a fully implemented palliative care model in place and working, working as we think it should be working, within hospice and hospital and elsewhere, what need is there for policies such as “Death with Dignity”? The one will follow, naturally upon the other. Is there a correlation or relationship between these two? Some might say, you don’t need Death with Dignity if you have a good palliative care model.

The focus should always be Life for that is what is precious. Life with dignity – until the very last breath of life!

It is always the journey that is paramount. Unless it is certain the terminus is close by anyway, it is always safer to continue to assist passage upon the journey. To keep to the well-trodden, familiar road is wiser than to follow the wayward ill-guessed track across foreign ground. That is the way of the death pathway.

The landmarks might be there and they may be familiar but to succumb to the pathfinder‘s insistence that they indicate Journey’s End is nigh, even though journey’s end is not yet in sight, that should not be a signal to hasten the journey.

If that life-focussed, quality palliative care is in place, and that care is attentive and caring, there is no need for the precipitous leap from the parapet the Pathway insists upon.

That is the mindless, tick-box mentality.