Liverpool Care Pathway - A Judgement Call

This is from the Catholic Medical Quarterly -

There are pertinent comments made here on the Liverpool Care Pathway and other matters. What is important and what is significant is what is being said, not who is saying it or for what reason.

This is not a debate between considered Christian ethics, on Catholic or non-Catholic dogma, and so-called progressive thinking but a judgement call on what is right and what is wrong.

Catholic Medical Quarterly Volume 61(3) August 2011,  20-22

WHAT MAKES FOR GOOD PALLIATIVE CARE?

Speaking at the CMA Conference in London in March, Dr Philip Howard pointed out that ordinary care was best defined by Pope Pius XII. “Normally one is held to use only ordinary means – according to circumstances of persons, places, times and culture - that is to say, means that do not involve any grave burden on oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health and all temporal activities are in fact subordinated to spiritual ends (Pope Pius XII 24/11/57. Address to Anaesthetists). According to John Paul II (2004), artificial nutrition and hydration are ordinary care and may not be denied. To quote; “I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered in principle ordinary and proportionate, and as such morally obligatory insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”

The principle of double effect has caused difficulty for some. All medical treatment has benefits, disadvantages and side effects. We are justified in treatment where it is necessary and where there are no other reasonable alternatives and where there is sufficient proportionality between the good effects and the side effects. So in palliative care you do not kill the patient to kill the pain. It is always necessary to use medicines with side effects having balanced the risks and benefits.

In fact double effect almost never applies in palliative care with opiates as in the correct doses they are almost always safe. But the wrong doses may be and are harmful and opiates can be used inappropriately.

CAN OPIATES BE USED TO SHORTEN LIFE?

Pius XII was asked in the 1950s if opiates could be used, even if they shorten life. Clearly, not as the primary purpose; Dr Howard pointed out, quoting Dr Margaret McKerrow, that with a little experience and knowledge, you know what you intend.

Pope John Paul II set out that nutrition and hydration are ordinary care except at the very end of life where hydration and nutrition may become physiologically irrelevant in the last few days of life. Throughout the history of medicine, even in pre Christian times, doctors have always recognized the value, dignity and worth of their patients. The Hippocratic Oath is predicated on the dignity of the individual. We learn that even in Hippocratic times, there were always physicians who would not abandon the city in times of plague. In more modern times, Victor Frankl who survived Auschwitz, explained the dignity of the individual even in the most appalling circumstances of the concentration camp.

As Victor Frankl said, “Fundamentally, therefore, man can, even under such circumstances decide what shall become of him both mentally and spiritually. He may retain his human dignity even in a concentration camp. Dostoevsky said once, “There is only one thing that I dread: not to be worthy of my sufferings.” These words frequently came to my mind after I became acquainted with those martyrs whose behaviour in camp, whose suffering and death, bore witness to the fact that the last inner freedom cannot be lost. It can be said that they were worthy of their sufferings: the way they bore their suffering was a genuine inner achievement. It is this spiritual freedom- which cannot be taken away- that makes life meaningful and purposeful.”

We can of course translate that suffering away from the concentration camp to those who suffer severe medical illness, as Frankl himself did. When we see how some of our patients bear the great suffering they face, it is an inspiration and can be one of the greatest rewards of our work.

Our job is to see the value of all our patients especially in the event of incurable and terminal illnesses. Our patients do carry crosses and it is our job to help and support them as they carry that cross, reducing their suffering. John Paul II tells us that we can suffer with, for and on behalf of Christ because He wills it, we are invited to share with him in His cross so that we may rejoice with Him in heaven. Our lives become extraordinary precisely because we participate in the redemptive actions of Christ himself.

CURRENT PROBLEMS IN PALLIATIVE CARE

At the CMA Conference in London last March, Dr Philip Howard suggested that palliative care has been transformed by the secular world around us in the last few years. On the wards there has been a change in attitudes with the introduction of terminal care pathways, the most familiar of which is the Liverpool Care Pathway (LCP).

We know that prognosis is not accurate and we often get our predictions of prognosis wrong. A tool based upon prognosis is therefore dangerous as it may become a decision that a person will die. Often on such pathways triple therapy is used (with morphine, midazolam a sedative and a hyoscine which is a drug to dry secretions). This means that the patient, who may or may not be dying, is given drugs that may hasten or even cause death. This is particularly true if hydration is also withdrawn. On such a regime the patient cannot survive. Sedation towards the end of life can also take away the freedom of the individual to see their families, set their affairs in order and attend to their religious duties and spiritual preparation for death. Deprivation of consciousness removes the moral freedom of the individual. Pius XII stated that this might be used in exceptional circumstances when other means to relieve extreme suffering were not available. But to do this routinely is wrong. In Holland deep sedation is used as a substitute for euthanasia and it may also be used where for legal reasons, the legal requirements for euthanasia are absent or the process of certification is regarded as too lengthy or difficult. We now see relatives sitting around the bed in the expectation of death. Where death does not occur soon, it may be a cause of complaint.

So we must return to the view that all persons are of worth while they live. There seems little doubt that lives are being shortened. The median time of patients on the LCP is 33 hours for cancer and 30 for non-cancer diagnosis. That is a matter of concern especially if we know that we do not know the precise prognosis in non cancer diagnoses.

Increasingly, in Holland, Belgium, the Netherlands and the States of Washington Montana and Oregon, we see moves towards euthanasia and physician assisted suicide (PAS). Increasingly even in jurisdictions that do not permit euthanasia and PAS, there is a move to terminal sedation which may be used a substitute for euthanasia.

REFERENCES

1. Address to an International Congress of Anesthesiologists, Official Documents. Pope Pius XII, November 24, 1957, L'Osservatore Romano,  November 25-26, 1957
2. Address of John Paul II to the participants in the international Congress on "Life-Sustaining Treatments and Vegetative State: scientific advances and ethical dilemmas" Saturday, 20 March 2004.

Liverpool Care Pathway - A Pathway Of Convenience

With the exceptions, perhaps, of the heroic and selfless act of the political martyr, such as Jan Palach in Wenceslas Square, or the odious religious fanaticism of one such as Hasib Mir Hussain in Tavistock Square, generally, the desire to suicide is not to die but to escape what is perceived to be an unbearable existence.

It is often the perception of being an unbearable burden upon others - family, loved ones - and to release these others as much as it is to release the self. It is not to depart this world, but to depart this existence.

This is The Mail Online -

The article concludes with pertinent comments on the Liverpool Care Pathway.

Allow medically assisted dying on the grounds of mercy, and soon it will be driven by convenience or greed

By STEVE DOUGHTY

PUBLISHED: 14:54, 17 August 2012 | UPDATED: 14:55, 17 August 2012

There will have been more tears than just those of Tony Nicklinson when the locked-in syndrome victim was caught in distress by the television cameras.

Few will have been immune to the suffering of an intelligent and once active man reduced to utter dependence on others. Here someone who is shut out from the simplest of the everyday exchanges that make the lives of most of us. He cannot go out alone, he can’t talk about what was on TV, the lives of celebrities, the football results.

One of the peculiar horrors of learning about the life of Mr Nicklinson is imagining what it would be like yourself to be entirely helpless for six hours every evening until a carer comes to wash you. Or to eat only soft mashed up food, and to drink only through a tube inserted into your stomach.

And to know it could happen to any one of us, anytime.

That gives Mr Nicklinson’s plea to die a universal relevance.

It is very hard to resist the appeal: doesn’t this man deserve the relief he wants? Why should he have to endure the unendurable? Is he to be made to bear decades of unnecessary misery for the sake of some legal technicalities and the tender consciences of a handful of right-to-life campaigners, many of whom are driven by a Christian faith he does not share?

For my part, the very reasons why I admire Mr Nicklinson are part of the argument that convinces me that the judges of the High Court were right to deny him the option of being killed by his doctor, and to say only Parliament has the power to grant it.

Pain: Mr Nicklinson is comforted by his wife after the High Court ruled that a doctor should not be allowed to help him die

Mr Nicklinson, it seems to me, is as fine an example as you could hope to get of someone who has made something of his life despite a disability of the most extreme kind.

He can communicate by blinking at letters held up by his wife Jane on a perspex board. He has an eye-blink word processor he describes as ‘a ray of sunshine on an otherwise bleak horizon’. He is writing his memoirs.

He has actively pursued to the High Court a case that would have exhausted or intimidated lesser men long before it came to judgement.

The road is open to fight this one through the Appeal Court, the Supreme Court, and on to the European Court of Human Rights, where Mr Nicklinson and his supporters may hope for one of the occasional Strasbourg rulings that overturn at a stroke decisions of British courts and Parliament.

Continue to fight: Tony, alongside his family, will continue to fight for the right to die at home surrounded by friends beyond the High Court ruling

Perhaps this is why Mr Nicklinson has his own version of St Augustine’s prayer about give me chastity, but not yet. According to Lord Justice Toulson his wish to die ‘does not mean that he necessarily wants to end his life immediately. At the moment he thinks that he would probably wish to end it in a year or two, but he wants to establish the right to die with dignity at a time of his choosing.’

I should make it clear that I do not for a moment doubt Mr Nicklinson’s sincerity or his determination to end his own suffering. But it seems that what may be keeping him going, for now, despite affliction that would crush most others, is his campaign for the right to be killed.

Mr Nicklinson certainly has the support of a large number of other right-to-die campaigners. They have backed a number of deeply sympathetic individuals from Diane Pretty to Debbie Purdy who have gone to the courts claiming the right to die.

Over the past 10 years they have successfully altered the law on murder so that now a caring family can expect to be able lawfully to help a desperately disabled or terminally ill member to die, most commonly in the Dignitas clinic in Zurich.

Some changes: Debbie Purdy, pictured here with her husband, successfully altered the law on murder so that now a caring family can help a desperately disabled or terminally ill member to die

Some of these campaigners are less compelling figures than Diane Pretty or Tony Nicklinson. Tony Blair’s former Lord Chancellor Lord Falconer, for example, who ran a supposedly independent inquiry ending in a report which, unsurprisingly, recommended a legal right for doctors to kill off their terminally ill patients.

Lord Falconer has tried and failed to persuade Parliament to back a bill allowing assisted dying. So have others. The House of Commons rejected an attempt to make statute law of the latest assisted suicide prosecution guidelines just five months ago.

It would be unwise to rely on the courts always to respect Parliament, especially since the European judges in Strasbourg have repeatedly shown they have no respect for Parliament at all.

So think about this.

Two months ago a very senior hospital consultant, Professor Patrick Pulliciano, said that 29 per cent of deaths of patients under NHS care now involve a process known as the Liverpool Care Pathway. This involves identifying patients who are dying, ending efforts to keep them alive, and easing their last days and hours. It can mean withdrawing water from a patient who is taking on fluid by tube.

Professor Pulliciano said putting a patient on the pathway is a ‘self-fulfilling prophecy’. He believes it may be used to free hospital beds or get rid of difficult patients. He thinks patients who might have lived are dying. He is not alone in the medical profession in his opinion.

If Professor Pulliciano is right, it may be that 100,000 NHS patients a year are dying prematurely.

This in a hospital system where wards are routinely filled with the old, sick, and friendless, and when there are suspicions that elderly patients can suffer neglect if they do not have families to watch over them.

Wards where patients are routinely asked to sign living wills that would allow doctors to withdraw life-saving treatment or have their beds marked with the notorious ‘DNR’ – do not resuscitate – signs.

Add in the numberless families where relatives do not wish the best to sick and elderly members, or cases where friends or hangers on are anxious to get their hands on the homes and money of the vulnerable, and you have the makings of a system where mercy and a compassionate wish to ease suffering do not govern the process of medically assisted dying.

You have murder.

Kevin Fitzpatrick, a researcher with the pressure group Not Dead Yet, has claimed that relaxing the law in this country would threaten old and disabled people as it would allow “moral judgements” that their lives were not worth living.

If it keeps you alive for a fortnight longer, it would be worth it

Charlie Cowper-Johnson

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. Such moral judgements, once taken, tend to gain broader boundaries of definition. 

It must be asked –

Would Lady Warnock’s comments actually encourage a presumption in the absence of the stated intention or desire embodied in a so-called living will?

Baroness Warnock said that for the old and sick who are contemplating dying 'there is nothing wrong with feeling you ought to do so'. But at whose and for whose convenience is that decision taken?

Liverpool Care Pathway – Patient Integrity Or Budgetary Constraint?

The LCP was designed as a tool to be used in the hospice setting – for patients already diagnosed to be terminally ill. It was not intended to be a tool to determine that diagnosis. The provision of hospice care applied in a non-hospice environment may be a laudable aim. However, in the circumstance that prognosis is not accurate and predictions of prognosis are often in error, such a diagnosis of terminality and the use of the LCP to reach that diagnosis must be utter folly.

There are interesting pertinent issues of interest here discussed -

This is from Hospice Patients Alliance.

Terminal Sedation: Is It Good Palliative Care or Euthanasia?

(HPA Newsletter 9/16/02 by Ron Panzer) Terminal sedation is in vogue among hospices throughout the world.  It is used in many niches within health care and the Intensive Care Unit of hospitals is another area where it is becoming more commonly practiced. The hospice arena of care is different from the I.C.U.  However, some of the discussion about terminal sedation in the I.C.U. highlights ethical issues confronting hospice personnel as well. Hospice medical directors hold in-services for the hospice nurses teaching them to use terminal sedation more frequently.  Families call in from all across the USA to Hospice Patients Alliance complaining that their loved one was sedated into death and did not die a natural death.  How are we to understand this issue? Today I received a phone call from a very experienced hospice R.N. who voiced concerns that the medical director of the hospice was "into" euthanasia and was teaching staff to use terminal sedation, even when the patient was not actively dying due to the natural disease process.  The recent concensus guidelines released in Canada provide a clear and vitally important definition of terminal sedation which demonstrates the difference between real terminal sedation and terminal sedation as it is being practiced in hospices all across the USA. The Canadian guidelines define "Terminal Sedation" as "sedation with continuous IV narcotics and/or sedatives until the patient becomes unconscious and death ensues from the underlying illness [emphasis added], [and] is palliative care, not euthanasia." "Since terminal sedation may arguably make the detection of euthanasia/assisted suicide more difficult, the intent of the Intensivist is crucial." What is important to note is that in the appropriate use of terminal sedation, the patient is sedated and death ensues from the underlying illness, NOT from the sedation itself!  If the patient is sedated and the patient simply dehydrates over several days and dies of circulatory collapse, not the disease process, then the "terminal sedation" is not palliative care, but imposed death: euthanasia.  If the patient is truly actively dying, and is then terminally sedated, the patient quite often does not have time to dehydrate, even though fluids are not being given, and the patient dies as a natural result of the terminal illness. The R.N. who called today stated that his hospice's medical director gave an example of a cancer patient without family support who wished to die at home.  The medical director stated that in such a case, terminal sedation was appropriate and the patient could be sedated into a coma simply because nobody else was in the home to care for the patient and because the patient did not want to die in a facility.  There was no mention of terminal agitation, delirium, severe anxiety related to respiratory problems or psychotic episodes ... in which sedation would be appropriate.  In other words, the medical director was asserting that it was "ok" to hasten death intentionally by using terminal sedation.  In fact, in the same hospice, a nurse on the hospice's ethics board told the group that they should look themselves in the mirror every morning and tell themselves, "I hasten people's deaths to eliminate their suffering, and that is ok." Anyone involved in hospice for any length of time knows that hospice is supposed to neither hasten death nor attempt to cure the underlying terminal illness.  And we all know that the American Nurses Association and American Medical Association have taken stands against euthanasia and/or physician assisted suicide.  However, that basic tenet of hospice has been replaced in many hospices by a willingness, even an eagerness to play God and hasten the patient's death through various means.  The perversion of "terminal sedation" being one of the most commonly practiced techniques. To any hospice professionals listening, I ask you to look yourself in the mirror and remember that in REAL terminal sedation, the patient dies of the underlying disease, not due to prolonged dehydration and consequent circulatory collapse.  I ask you to remember that it is the patient's right to determine whether or not they are sedated and that good practice demands that sedation only be used when clinically appropriate, i.e., for severe anxiety, agitation, delirium and psychotic episodes which cannot be managed in any other way. If hospice is to maintain its integrity, the practice of terminal sedation must be severely restricted to only those clinical situations which demand sedation and not be used routinely, as is becoming extremely common in hospices.  Hospice is in danger of becoming simply a death mill where patients are eliminated (after collecting reimbursement from services for a few days) and hospice professionals have no need of palliative care knowledge or expertise.  Excellent references such as the new palliative care reference from Saunders publishing:  End of Life Care - Clinical Practice Guidelines , which details in great depth how to manage numerous scenarios confronting those at the end of life ... may become unnecessary. If hospices routinely misuse terminal sedation on most of their patients, then it is my belief that licensed nurses may be completely unnecessary.  Standards of care may become unnecessary.  All that would be needed is for patients to take large doses of sedatives and narcotics without any medical justification. Hospice "techs" could be hired to do the terminal sedating and hospice corporations can maximize their profits or revenue stream.  Why bother with real palliative care?  Why bother hiring experienced palliative care nurses or doctors?  Why bother providing the type of care which is at the heart of hospice since its beginning?  Those who practice euthanasia (even slow euthanasia such as the misuse of terminal sedation)  under the radar without calling it "killing" don't really care about palliative care and the patients or their families.  They don't care that most terminally ill and their families believe that every month, week and day ... even every moment the terminally ill patient is still alive is precious and to be valued and remembered. Hospices that violate the sanctity of the patient's and family's trust by terminally sedating a patient without consent or against his or her will are doing the greatest damage to the hospice industry itself, because the families of the dying remember forever what happened in their hospice experience. These families who are betrayed by hospice staff will never use hospice services again, and that bitterness extends to the hundreds of others in their extended family.  If hospices want greater utilization of their services; if the federal and state government want greater utilization of hospice services (and they do in order to save billions of health care budget dollars) they urgently need to re-evaluate the perversion and routine misuse of terminal sedation.  Hospices need to return to the standards of care that made hospice so well respected by those who were well served by hospice! Hospice at its best is at risk for becoming hospice at its worst: simply a death mill where death is imposed upon the patient before the terminal illness would naturally take the patient's life.  Hospice nurses and physicians should think well about where the encouragement to use terminal sedation is coming from.  Perhaps it is coming from those who wish to minimize expenditures for hospice services:  the HMOs, or even federal or state budgetary concerns.  It certainly doesn't come from a place of respect for the patient and their family! Hospices: beware of the direction you take, because the wrong road will only destroy the very essence of hospice along with its reputation and its mission!

Liverpool Care Pathway – A Communitarian Pathway

Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel, proposes a ‘complete lives system’ of healthcare.

This is an extract from the paper he joint-authors with Govind Persad BS ^a and Alan Wertheimer PhD ^a, published in The Lancet –

“Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on,' but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.”

This is called “communitarianism”.

Communitarianism is already up and running, here, in the UK. 

‘Quality of life’ assessments are being made to determine who is treated and who is not.

Those with learning disability, those mentally impaired in whatever manner or form, the old, the vulnerable, are not being selected for treatment.

These are the victims of “communitarianism” by omission. 

There are victims of “communitarianism” by commission, given DNR notices or slapped onto the LCP.

Here – 

Liverpool Care Pathway – The Perfect Fit Solution

Here –

Liverpool Care Pathway – In Place Of Ageism

And here –

Liverpool Care Pathway – If The Facts Fit...

The old and the disabled, by mental or by physical impairment, are at risk. But let us make it plain,- there are no untermenschen.

That is not to say, however, that there are no ubermenschen.

All menschen are equal, but some menschen are more equal than others!

Liverpool Care Pathway – A Frightening Care Pathway

This is really frightening, that our lives are in their hands. Our fate is a fait accompli. We are at their mercy…

This is MAX PEMBERTON in The Telegraph:

By Max Pemberton

7:00AM BST 07 Sep 2009

Comment

The telephone rang. From the tone of my Gran's voice I knew immediately it was bad news. "The doctors have said they think he's going to die," she said quietly. "He's in intensive care but they think he won't last the night". I know that when doctors talk about someone dying then it there really isn't much hope.

My grandfather had been taken into hospital earlier that day with a distended abdomen. He was having difficulties breathing and had become increasingly confused. He had been admitted to a ward and arrangements had been made for him to have a scan that same day. He had been given a drink containing contrast medium that would make the image of his bowels clearer, but while he lay in the scanner he had vomited and inhaled it. He then rapidly developed pneumonia, making his breathing even worse. Blood tests had shown that the oxygen in his blood was dangerously low. He was now on intravenous antibiotics and high-flow, pressurised oxygen but was having difficulty tolerating the mask over his face, so the doctors had been forced to sedate him. Now his breathing had changed from being deep and laboured to short, shallow breaths. He was no longer struggling to get enough oxygen into his lungs.

No pill or potion is a

match for compassion

The doctors, my Gran carefully relayed to me, warned her that this was because his body was now giving up and it was only a matter of time. My Gran didn't need to explain this to me, because I have seen it so many times before. This, I thought as I listened to her, is the typical pattern of how old people die. One thing after another, the body gets weakened, underlying problems hamper recovery, infection sets in, doctors do their best but it's futile. While personally it was devastating, medically, it was unremarkable. Any objective analysis based on medical knowledge would have assumed that my grandfather was about to die. But he didn't. He survived the night and by the morning, he had rallied. The next day, he was off the oxygen. The day after that, he was sitting out and eating some custard.

I have often seen this happen; patients you are convinced will follow a clear, definable illness-trajectory prove you wrong. It's this unpredictability that makes medicine so fascinating; the fact that the body has a remarkable capacity to confound expectations. Even for those with a terminal illness, there can be no certainties. It's for this reason that I despair of the Government's new treatment pattern for palliative care. The "Liverpool Care Pathway" involves a series of tick-box assessments, which aim to assess the likelihood of death in patients deemed to be terminally ill in hospitals, nursing and residential homes.

Under these guidelines, being rolled out across England, patients can have fluid and drugs withdrawn while on continuous sedation until they die. In a letter to this newspaper last week, experts in palliative care raised concern about this system, highlighting that this approach can mask the signs of improvement. They argued that "forecasting death" is an inexact science. I think there is a valid argument for withdrawing treatment from patients in pain and distress and making them comfortable.

As doctors, we must be aware that actively treating someone can unnecessarily prolong suffering. For this reason there is no doubt that doctors need guidance on how to manage those patients with terminal illness. But any doctor knows that the decision to withdraw treatment is an incredibly complex one, involving professionals from a wide range of disciplines including a palliative care team, and can never be as simple as filling out a sheet on a clipboard. As frustrating as it is to those in power, medicine cannot be reduced to a series of tick-boxes. Things just aren't that simple. It's why medicine is talked of as being as much an art as a science. It operates in uncertainties and requires reflexivity, adaptability and judgment that a reductionist approach can never do justice to. A bureaucratic approach to medicine is that it stops professionals from thinking. It stops them from questioning their decisions and from seeing each patient as an individual. Not only does this result in dangerous complacency, it denies the wonder of the human body. On paper, my granddad was about to die. In reality, against all the odds, he rallied and although he's still in hospital, is doing very well. He's probably reading this now. Get well soon Gramps.

Predicting death in a time frame of three to four days, is not possible scientifically

Professor Pullicino

Nothing is ever a foregone conclusion. We are not Gods: we cannot tell with certainty, but must work with the situation and the individual.

I have highlighted pertinent sections of Max Pemberton’s contribution to demonstrate how the LCP removes all responsibility for decision-making, as is illustrated in this young doctor’s account:

AUGUST 11, 2012

On Call Week: Liverpool Care Pathway, STAT

Apologies for the delay since my last post. I was on call in a hospital that seems to confuse ‘on call’ with ‘how to avoid hiring locums’. Usually, when a junior doctor is on call, the other juniors in his or her normal team step up and get the ward jobs done. I can imagine it would be an excellent team building experience, ranking alongside mummifying the teacher in toilet roll at the end of the summer term. The folks at Princess Royal Hospital decided it would be even better for our team spirit if the only junior doctors on the medical admissions unit went on call together, leaving no one to attend the post take ward round or do the ward jobs. We had no choice but to continue with our normal jobs, whilst being responsible for clerking in every new admission to the hospital and providing cover to all the wards and of course attending all emergency calls. Our survival is an achievement worthy of an Olympic gold, and though I feel multiple human rights have been violated in the process, I am definitely a better doctor for it.

There were many learning experiences I want to share. Perhaps the most poignant one was writing up the Liverpool Care Pathway for an 87 year old man with multiple co morbidities and a likely terminal episode of pneumonia. I saw the consultant write up the drug chart in A&E in a matter of minutes at around 0930. By 1400, the patient was an AMU and the drug chart had gone missing. The patient had hours to live at best and my consultant, who was the only person in the hospital who knew this patient, was in a meeting. I hadn’t even seen the patient when I was asked to re-write his LCP medication.

My stream of consciousness went something like this: What dose of morphine should we use? I don’t know if he is opiate naive…does it matter at this stage? Can an F1 write big doses of morphine up? Oh, he’s on oxygen. Does that have to stop? It’s symptom relief only…but does the oxygen make him feel less breathless? Maybe we could monitor his sats and see if he needs it…but hold on, is that invasive monitoring? He looks dry, and I’m pretty sure the LCP says that actually you can use artificial hydration, I remember a case study on the GMC website. How can I tell if he is agitated, or in pain? Do the family decide…

As ever, when in doubt with a prescription, I speak to a pharmacist. These are the most amazing people in the hospital. They are fountains of knowledge raining on the gasping fish out of water that is the F1 asked to make a decision about which drug to use.

“Hi. I need help.”

“What is it?”

“I’ve been asked to prescribe the LCP to a terminally ill patient. How do I write up a syringe driver? How do I decide the rate and dose? How do I…”

“Here.”

She produced a LCP booklet that was about 30 pages long. I started reading from the front, which felt like opening a new TV and reading the company propaganda from Sony when it’s pretty clear that the things I really need are going to be later in the booklet. I never understand why companies insist on selling you the product in the first few pages after you have clearly just bought it.

I skipped forward to the prescribing section. There were five pharmaceutical targets to the care:

1. No pain

2. No vomiting/nausea

3. No agitation/restlessness

4. No respiratory distress

5. No respiratory secretions

The management of each of these depended on whether or not the patient was already experiencing the symptom. If the patient had the symptom, an appropriate drug should be written up as a syringe driver with a PRN subcut breakthrough dose. If the patient were not yet experiencing this symptom, then a PRN dose should be prescribed. As I began attempting to fill in the prescription chart, I realised I could not write anything unless I knew what the particular needs of my patient were. I decided to see the patient.

The patient was a tall man who had clearly lost weight recently. Folds of skin hung loosely off bones that are not meant to be so easily visible. He was breathing rapidly but with shallow breaths, with each inspiration accompanied by what sounded like basal crepitations but amplified and coming out the mouth. He did not seem to be in pain, but how do you tell in a patient who is not verbalising or even vocalising? He was as peaceful as he could be with all the secretions in his respiratory tract, and his respiratory rate was around 16.

I asked the nurse looking after him what she thought about his symptom control over the last few hours. I also spoke with his daughters to work out what symptoms (if any) were bothering him most in the last few days.

For pain, we looked through the notes, including his previous prescriptions, and there was no suggestion of any pain nor any history of painkillers above PRN paracetamol. I decided to use PRN diamorphine 10mg s/c for pain control based on   the LCP recommendation.

The patient had not been vomiting or expressed any nausea. PRN haloperidol 1mg s/c was the medication of choice for this scenario. As the patient appeared to be opiate naive, and 10mg diamorphine is a pretty big first dose of opiate, there was a significant risk of inducing vomiting in his last few moments alive, which needed antiemetic cover.

The advantage of haloperidol was that is was also useful for agitation and restlessness. The patient had none of that at the moment, so a PRN dose was all that was needed. The other option recommended was midazolam, which would be more sedating. As his daughters were around and presumably wanted to speak with him, I preferred the less sedating option.

I have since learnt that respiratory distress is often tied to anxiety in the dying patient, and both should be treated together. Relaxation exercises and physiotherapy, as well as basic treatment like sitting the patient up if tolerated, can be helpful. Medically, morphine can be used PRN. There was no need to write up any additional medication in this case. We decided that oxygen was not needed, as the mask was probably uncomfortable and as the respiratory rate did not increase with the oxygen off, the patient probably was not in respiratory distress. I realise that I am making the assumption that respiratory rate and respiratory distress have the usual relationship that they have in non palliative medicine. If anyone has anything to add on this I would be really grateful.

Finally, the respiratory secretions. The patient had symptoms, so needed hyoscine hydrobromide. I gave this as a subcut syringe driver over 24 hours, with a PRN top up as needed.

I didn’t have long before I was back to my usual on call routine of pretending to be in 3 places at once. But just for a few minutes, I felt like a doctor who was independent from the chaos in the rest of the hospital. I was making the care of my patient my one and only priority, and it was rewarding.

Patient UK 

Tees, Esk and Wear NHS Trust’s implementation of the LCP

I have highlighted pertinent sections of the young doctor’s contribution to demonstrate how the LCP removes all responsibility for decision-making.

An 87 year old man is described as having co morbities. In medicine, co morbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest. A ‘likely’ terminal episode isn’t even a diagnosis.

As for being an ‘AMU’, patients are routinely shifted out of A & E into the AMU (Acute Medical Unit) as a box-ticking, ‘creative accounting’ device to reduce apparent waiting times and make everything look good on paper.

By 14.00, the drug chart written up by the consultant, the only person in the hospital who ‘knew’ this patient, had gone missing. Even so, the young doctor who ‘hadn’t even seen the patient’ was asked to re-write the medication!

The LCP recommendations are as highlighted further down in the young doctor’s account.

If the symptom is there, prescribe; if it is not, prescribe in any case! The LCP is a self-fulfilling pathway that excuses the actual responsibility of decision-making.

But the young doctor, from his account, considers his individual patient. Is the young doctor learning what Max Pemberton calls the 'art' of medicine?

Here is a young doctor actually taking responsibility for decision-taking, making 'assumptions' from his own clinical experience, which is all any good doctor can be expected to do.

The young doctor acted, clearly, according to what he felt were his patient's best interests. It is only to be hoped that the outcome was not already pre-determined by being placed on the Liverpool Care Pathway.

Liverpool Care Pathway – Fur Das Wohl Des Staates

President Obama famously complained that the US constitution,

"says what the state and federal government can't do to you; it doesn't say what it should do for you".

These are pages from the website of AIT (American Institute in Taiwan) –

  

Introduction

We hold these Truths to be self evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty, and the Pursuit of Happiness — That to secure these Rights, Governments are instituted among Men, deriving their just Powers from the Consent of the Governed.
— United States Declaration of Independence

Above: Thomas Jefferson and John Adams were two of the chief authors of the U.S. Declaration of Independence. Below: James Madison, generally seen as the "father of the U.S. Constitution."

These words from the Declaration of Independence have always had a special meaning for the people of America.

It is one of our charters of freedom, recited at countless gatherings every Fourth of July, memorized by generations of schoolchildren, invoked by politicians of every party, and frequently cited by the courts in their decisions. Its message, which resonates as forcefully today as it did over two centuries ago, is that protection of the rights of the people is the antecedent, the justification, for establishing civil government. The people do not exist to serve the government, as is the case in tyrannical societies, but rather the government exists to protect the people and their rights. It was a revolutionary idea when first propounded in 1776; it still is today.

John, Lord Acton, The History of Freedom and Other Essays (1907) Liberty is not a means to a higher political end. It is itself the highest political end.

In the essays that follow, I have tried to explain what some of the more important of those rights are, how they are integrally connected to one another, and how as a matter of necessity their definition changes over time. We do not live in the world of the 18th century, but of the 21st, and while the spirit of the Founders still informs our understanding of constitutionally protected rights, every generation of Americans must recapture that spirit for themselves, and interpret it so that they too may enjoy its blessings.

This last paragraph falls in line with Mr. Obama’s reference to the Constitution being a living document. However, this ‘recapturing of spirit’ is always accomplished with care, consideration and humility.

Quote of note:

"The people do not exist to serve the government, as is the case in tyrannical societies, but rather the government exists to protect the people and their rights. It was a revolutionary idea when first propounded in 1776; it still is today."

In 1787, shortly after the Philadelphia convention adjourned, James Madison sent a copy of the new U.S. Constitution to his friend and mentor, Thomas Jefferson, then American ambassador to France. On the whole, Jefferson replied, he liked the document, but he found one major defect-it lacked a bill of rights. Such a listing, Jefferson explained, "is what the people are entitled to against every government on earth." Jefferson's comment surprised some of the men who had drafted the Constitution; in their minds, the entire document comprised a bill of rights, since it strictly limited the powers of the new government. There was no need, for instance, of any specific assurance that Congress would not establish a church, since Congress had been given no power to do so. But Jefferson, the chief architect of the Declaration of Independence, believed otherwise. Too often, in the past, governments had gone into areas where supposedly they had no power to act, and no authority to be, and the result had been a diminishing or loss of individual rights. Do not trust assumed restraints, Jefferson urged, make the rights of the people explicit, so that no government could ever lay hands on them. Many people agreed with Jefferson's sentiments, and several states made the addition of a bill of rights a condition of approval of the new Constitution.

Quote of note:

"Too often, in the past, governments had gone into areas where supposedly they had no power to act, and no authority to be, and the result had been a diminishing or loss of individual rights. Do not trust assumed restraints, Jefferson urged, make the rights of the people explicit, so that no government could ever lay hands on them. "

These two quotes fit very well into the controversy surrounding the new health bill going through the US Congress which provides that the government will decide, over the heads of the people, what is best and how and in what manner care shall be administered.

This is discussed here –

    Liverpool Care Pathway - A Utilitarian Pathway

Do not trust assumed restraints, Jefferson urged.

Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel, is leading the US government into areas where supposedly it had no power to act.

In the paper he joint-authors with Govind Persad BS ^a and Alan Wertheimer PhD ^a, published  in The Lancet, Dr. Emanuel proposes a ‘complete lives system’ of healthcare.

“Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on,' but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.”

This is called “communitarianism”.

The fact is that the “communitarianism” (complete lives system) advocated by Dr. Emanuel and his co-authors is only Utilitarianism by another name. There is little difference between determining who is more worthy - Ubermenschen - than who is less - Untermenschen.

This table is extracted from the Paper. It indicates the prioritisation of medical intervention which the authors favour.

Emanuel has defended himself by saying he has been quoted out of context from an academic work. However that is or is not the case, he is still responsible for floating the idea and thus advancing an invidious trend.

With the intended aim of 'designing' – dumbing down - public opinion into an acceptance of the unacceptable, ideas are being aired, mentioned in these pages.

Do not trust assumed restraints, Jefferson urged.

Quote of note:

"The people do not exist to serve the government, as is the case in tyrannical societies, but rather the government exists to protect the people and their rights. It was a revolutionary idea when first propounded in 1776; it still is today."

In the UK, people are being murdered to save the State money. By definition, then, ours is already a tyrannical society. The US is becoming one.

Ich existiere fur das Wohl des Staates (I exist for the good of the state).