Liverpool Care Pathway - So Readily Do Perceptions Change...

Just one more step further... That won't matter too much; will it?
Else do they fall in breach of Article 8...?


It was Beverley Broadbent’s considered decision that it was time to go...

Read further here –

Liverpool Care Pathway - And "Rational" Suicide

Such decisions may grow in the mind like a gnawing tooth that aches the soul, a mounting surge too much to bear, until the act demands that it be undertaken.

Such decisions may overwhelm and prompt the act to be followed through with a rashness and urgency that requires no forethought, more an impulse than requiring reason.

Such decisions, weighty, ponderous, may require that they be shared with others. An act of such finality and consequence may demand such counsel.

For Beverley Broadbent, the imperfections of her age, the loss of balance, were sufficient that she chose to end her life. Her counsellors were Fairfax Media and Euthanasia champion, Rodney Syme.

Beverley Broadbent was a political activist. Taking her life, also, was a political act.

Beverley Broadbent was mixed up with a lot of shady characters. Syme is president of the Voluntary Euthanasia Society and a sidekick of Dr. Death Nitschke. Nitschke and Melbourne activist Dr Rodney Syme have, individually and in collusion, advised countless Aussies on how to end their lives.

Syme said he believed she had not been depressed but had made a choice that many other elderly people would like to emulate. It was Beverley Broadbent’s expressed belief, also, that there are many elderly people like herself who want to die when they feel their life is complete.

This was not 'rational' suicide but the irrational imperative of the group; this was the collective psychology of the herd. The solidarity of common cause reinforced her resolve and her commitment to the idea.

Her political commitment to the group reinforced the resolve to act upon her decision.

This irrational imperative is become a creepage, imperceptible but sure, that has insinuated itself into the mainstream of what is considered reasonable and acceptable.

This is The Telegraph –

A Swiss organisation that assists people in ending their own lives has voted to widen its services to elderly people who are not terminally ill.

Exit chose to add “suicide due to old age” to its statutes at an annual general meeting to allow people suffering from psychological or physical ailments linked to old age the choice to end their life.

Assisted dying is legal in Switzerland and in theory even a healthy young person could use such services. However, internal rules vary from group to group.

The move has been criticised by the Swiss Medical Association amid fears it will encourage suicide among the elderly

“It gives us cause for concern because it cannot be ruled out that elderly healthy people could come under pressure of taking their own life,” said Dr Jürg Schlup, the association’s president.

The Coalition plans a pension overhaul next year to save money. Pensions Minister, Steve Webb, has suggested that retirees could be supplied with a projection of their life expectancy to better plan ahead their available financial resources. Steve has many tools available to him to make that determination.

Further reading –

Liverpool Care Pathway - Appointment With Death

The pieces of the jigsaw are fitting together. The bigger picture is becoming clear...

The Complete Lives system is our pathway trajectory. We are given our appointment with death. Or we choose our own. The new Euthanasia Bill is installed to accomplish that death.

That is scaremongering; that is not the intent of the Bill...

Once the door is opened an inch, what difference will one more centimetre make? Opening the lid to permit a peep further is all it is.

The landscape has already changed. Are the ideas of Warnock and Amis as outrageous as they once were?

Read further here -

Liverpool Care Pathway - The Intrusion Of The Unacceptable Into The Ethical Mainstream

Beverley Broadbent described old age as a disease. Old Age is become, by definition, then, a terminal illness - a justification to permit euthanasia!

Beverley Broadbent’s considered decision was founded on the personal assessment that her life lacked that quality it once had. Are these the grounds upon which she and Syme and others of his ilk have proposed should be those upon which such decisions should be based: that life lacks that sparkle, that gleam it once had?

May healthy disabled people be classed in this category and fit the justification criteria to permit euthanasia...?

And when is euthanasia not euthanasia...?

When it's 'medical aid in dying'!

When it's 'medical aid in dying'...

Isn't that the LKP?

Quebec's social services minister has a passion and a purpose in her eyes. Veronique Hivon strikes a pose and thunders her belief that "medical aid in dying" will absolve doctors of criminal responsibility.

This is the Toronto Star –

Legislation introduced Wednesday by the Parti Québécois government would allow doctors to administer lethal drugs to a exclusive group of patients whose lives are nearing the end and who are in excruciating pain that cannot be relieved by drugs.

The bill, which deals broadly with end-of-life care, would also expand access to palliative services across the province and bring formal rules that govern how and when doctors can sedate patients until they die of natural causes.

They are brimming with purpose...

...and compassion.

In Belgium, in Flanders fields, where one step has already lead to many, this is Flanders News –

The deacon is believed to have helped patients put an end to their lives without following the strict regulations. It is also not clear whether the patients gave their full consent.

At a press conference this morning, a spokesman for the local judicial authorities in West Flanders could not confirm that the patients gave their consent, which would change the accusation into "murder". At the same time, he would have been engaged in the practice for a period of 31 years, with possibly many more victims than just 10.

When is euthanasia not euthanasia...?

When it’s "illegal euthanasia".

But...

a spokesman for the local judicial authorities in West Flanders could not confirm that the patients gave their consent, which would change the accusation into "murder".

And then it's murder.

Without consent, it's murder.

This is CMAJ –

We found that the use of life-ending drugs without a patient’s explicit request occurred more often in Flanders, Belgium, than in other countries, including the Netherlands, where euthanasia is also legal. Flemish physicians have been shown to be more open to this practice than physicians elsewhere, which suggests a larger degree of paternalistic attitudes. This being said, its occurrence has not risen since the legalization of euthanasia in Belgium. On the contrary, the rate dropped from 3.2% in 1998 to 1.8% in 2007.12 In the Netherlands, the rate dropped slightly after legalization, from 0.7% to 0.4%.11 Although legalization of euthanasia seems to have had an impact, more efforts are needed to further reduce the occurrence of life-ending drug use without an explicit request from the patient.

Paternalistic Flemish physicians have taken life without “explicit request”.

Without consent, it's murder.

This being said, its occurrence has not risen since the legalization of euthanasia in Belgium. On the contrary, the rate dropped from 3.2% in 1998 to 1.8% in 2007.12 

However, continuous sedation until death is being increasingly used in place of euthanasia in Flanders...

Dr. Judith Rietjens says:

The use of continuous deep sedation may in some situations be a relevant alternative to the use of euthanasia for patients.

They are playing with words. It's all semantics. It's all word games. But this is not a game.

This is a study posted in Palliative Medicine on Sage Journals. It is titled, 'Physician-reported practices on continuous deep sedation until death: A descriptive and comparative study'.

The authors include contributors from the International Observatory on End of Life Care at Lancaster University and the End-of-life Care Research Group from Ghent University, Belgium -

Artificial nutrition and hydration was withheld or withdrawn in 97.2% of general practitioner and 36.2% of medical specialist cases. Explicit life-shortening intentions were reported by both groups (for 3%–4% of all cases). Continuous deep sedation until death was initiated without consent or request of either the patient or the family in 27.9% (medical specialists) and 4.7% (general practitioners) of the cases reported.

In a Letter to the Editor, arguing semantics, the EoLC Research Group made the following observations –

Re: A response to Willis et al.

We share Dr Willis’ view that there is a need for a clear-cut and widely agreed upon term and definition for the practice of sedation at the end of life.

…sedation is said to be different from the practice of euthanasia. However, our study shows that in practice – although in many cases this distinction is clearly experienced by professional caregivers – they sometimes experience difficulties distinguishing the user of sedation from the practice of euthanasia.

The End-of-Life Care Research Group conducted 'The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study' –

In 2007, palliative sedation was used in 14.5% of all deaths in Flanders. The main aim of this study is to gain insight in the characteristics of the practice of palliative sedation and its contribution to the patient’s quality of dying and the wellbeing of their relatives in three countries: Flanders, the Netherlands and the UK. It has an innovative mixed-methods design, consisting of quantitative analyses of existing high quality databases and 270 qualitative interviews with physicians, nurses and relatives. The study will improve our understanding of the clinical characteristics and determinants of terminal sedation, and will enable the development of evidence-based strategies to improve this end-of-life practice.

Surveys of medical decisions at the end of life raise questions about the use of sedation until death, and there are concerns about the use, intentions, risks and significance of the practice in palliative care delivery. There are also questions about how to explain international variation in the use of  the practice. The UNBIASED study (UK Netherlands Belgium International Sedation Study) comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands to conduct an in depth study of the use of this practice at the bedside in the three countries.

This was a study into continuous deep sedation which included the UK.

Read further here -

Liverpool Care Pathway - The Steps Into That Darkness Are Always Gradual, But Ever Certain

The End-of-Life Care Research Group has intensive international collaborations, mainly with research groups in Canada, Denmark, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, the UK and the USA.

The research group is also sponsoring a Cluster Randomized Trial of the Liverpool Care Pathway study posted on Clinical Trials, the US National Institutes of Health website -

Although the LCP has been adopted in 21 countries outside the United Kingdom and has been recognized to be the gold standard for practice, the evidence supporting such practice is insufficient. In a Cochrane review some qualitative and uncontrolled before-after studies are mentioned but no eligible RCTs, quasi-experimental studies or controlled before and after studies could be identified. Due to the scarce of available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made at the present time. RCTs or other well designed controlled studies are thus needed to obtain additional evidence about the effectiveness of the LCP. 

We will contribute substantially to the increase of evidence for the effect of the Liverpool Care Pathway on end-of-life care in elderly patients dying in acute geriatric hospital wards in Flanders. A cluster randomized controlled trial (cluster RCT) model for the study will be used. 

The aim of this cluster RCT is to evaluate the effectiveness of the Flemish LCP in improving the quality of care and quality of life during the last 48 hours of life of patients dying in acute geriatric hospital wards in Flanders as compared to usual care.

Further reading -

Liverpool Care Pathway - A Review Of The Muchness of Much Less

Although the LCP is recognised and recommended as the gold standard practice by a baker's dozen of the great and the good, including Wee Bee Long, Margaret Kendall and Age UK which is currently sharing its toilet facilities with a dodgy euthanasia charity...

The Liverpool Care Pathway has been suggested as a model of good practice in the last hours and days of life by successive national policy frameworks (DH, 2003 and 2006), the national End of Life Care Strategy (DH, 2008), Quality Markers and Measures for End of Life Care (DH, 2009), General Medical Council guidance (2010) and the NICE quality standard for end of life care for adults (2011).
- http://www.bgs.org.uk/pdf_cms/reference/lcp_consensus.pdf

Although the LCP is recognised and recommended as the gold standard practice by NICE and the DoH EoLC Programme run by the NCPC, the evidence supporting such practice is insufficient. It is wanting...

Due to the scarce of available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made at the present time. RCTs or other well designed controlled studies are thus needed to obtain additional evidence about the effectiveness of the LCP. 

Margaret Kendall has put the name of her group to the Consensus Statement signed in September 2012. This was the National Nurse Consultant Group (Palliative Care)...

Have you settled on a name, then, Margaret...?

Here is Margaret Kendall with her Joint Statement in October 2012 on behalf of the same group, this time grandly called the Consultant Nurses in Palliative Care Reference Group...

Essential reading -

Liverpool Care Pathway - Of Deception And Infamy 

Liverpool Care Pathway - Of Deception And Infamy (Part II)

This is a great fraud being perpetrated when they may cite each other and one another as reference for independent verification when it is all just the Emperor's new clothes and the 'evidence' is just a whiff of stale air – hence the six known pseudonyms adopted by the Kendall group. It gives the appearance of further 'independent' substantiation of claims.

In the news this week, Addenbrookes Hospital, Cambridge has been found by The Court of Appeal to be in breach of Article 8 of the European Convention of Human Rights...

This is Cambridge News –

The Court of Appeal has ruled the human rights of a terminally-ill patient were violated when a “do not resuscitate” notice was placed on her records at a Cambridge hospital without her being consulted.

Care home manager Janet Tracey was 63 when she died following a transfer to Addenbrooke’s after breaking her neck in a car crash in 2011 – two weeks after being diagnosed with terminal lung cancer.

Lawyers acting for her family have described it as a “landmark judgment” clarifying that NHS trusts have a legal duty to tell patients with mental capacity that a Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) order has been placed on their medical records - and to involve them in the decision-making process.

In this morning’s judgment, Master of the Rolls Lord Dyson, said: “A “DNACPR decision is one which will potentially deprive the patient of life-saving treatment, there should be a presumption in favour of patient involvement. There need to be convincing reasons not to involve the patient.”

He went on to warn that “doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them”.

Speaking after the judgment, husband David Tracey said: “We’re all so pleased that the court has agreed that imposing a do not resuscitate order on Janet without consulting with her was unlawful.

“It feels as though the wrong done to Janet has been recognised by the court and the fact that her death has led to greater clarity in the law gives us all some small comfort.

Without consent, it's "murder"...

It has become an imperative of policy to install euthanasia on the statute book.

The Appeal Court judgement is here –

The following is posted under court of protection cases on ThirtyNine Essex Street –

David Tracey, acting personally and on behalf of the estate of his deceased wife, Janet Tracey, brought an application for judicial review against (i) Cambridge University Hospitals NHS Foundation Trust in relation to the placing of two Do Not Attempt Cardio-Pulmonary Resuscitation (“DNACPR”) Notices on Mrs Tracey’s medical notes at Addenbrooke’s Hospital and (ii) the Secretary of State for Health for failing to promulgate a national policy in relation to DNACPR notices.

Mr Tracey appealed to the Court of Appeal and his appeal was allowed. Longmore LJ (with whom LJ Ryder and the Master of the Rolls agreed) held that the submissions made on behalf of Mr Tracey could not be dismissed out of hand and the judicial review application (which was substantially refocused before the Court of Appeal), should therefore go forward to a hearing. Longmore LJ said (at paragraphs 17-19):

“17. It does not appear that the judge thought that the points in relation to explanation or consultation with the patient or the right to a second opinion were themselves unarguable. She thought that in the light of her findings of fact they were ‘academic’ and that any failure to follow policy or have the right policy did not cause Mrs Tracey's death. I do not agree that the case can be disposed of in this way. It is not academic because there can be no doubt that … Mrs Tracey was distressed when she learnt that the first notice had been placed on her notes. Part of that distress was because she thought that her family had either asked for it to be so placed or had, at least, agreed to it. When that became plain, it distressed the family as well. In these circumstances, the judgment's reference to the absence of causation is, with respect, misplaced since there were consequences of the first notice. If those consequences had been ‘trifling’ the judge might have been correct to say the case should go no further but it cannot be right to call the distress suffered by Mrs Tracey and her family as ‘trifling.’ The points on consultation and a second opinion are, moreover, matters of some general importance.

18. The judge's fear of a wide ranging inquiry which might need expert evidence is likewise misplaced now that Mr Havers [acting for Mr Tracey] has confined his case …. The question whether the absence of explanation or consultation or the failure to offer a second opinion means that the placing of the first DNACPR Notice was unlawful as being an unjustified breach of Article 8 of the Convention is, of course, a question of law on which expert evidence would be neither admissible or appropriate.

Comment 

We note with interest that the important issues raised in this case about decisions not to attempt resuscitation will be the subject of a substantive judgment from the Court of Appeal in the not-too-distant future. Longmore LJ considered that the case should be retained by the Court in the light of the very considerable public resources already expended as, in his view, there was a great danger that any decision at first instance would itself be appealed.

Readers are likely to be particularly interested in the Court of Appeal’s adjudication upon the lawfulness of the DNR policy and whether Article 8 imposes a duty upon medical professionals to consult with a patient (or their family, if they are incapacitated) before imposing a DNACPR notice, bearing in mind the weight of judicial authority establishing that neither a patient nor their family can require a doctor to administer treatment which that doctor does not consider to be clinically indicated (see R (Burke v General Medical Council [2006] QB 273 paras 50-55 per Lord Phillips and Aintree University Hospitals NHS Trust v James [2013] 3 WLR 1299 para 18 per Baroness Hale, cited by Longmore LJ at paragraph 11).

Additional reading -

Liverpool Care Pathway - There Are Always Consequences 

Liverpool Care Pathway - Over Here, Over There, And Coming Your Way Soon

Liverpool Care Pathway - Who Possess No Moral Humility Possess No Moral Restraint

This is not noble self-sacrifice the Communitarian asks...

The search for Spock: 

Don't grieve, Admiral. It is logical. The needs of the many outweigh......the needs of the few.

Or the one. I have been and always shall be your friend. Live long and prosper.

Why would you come back for me?

Because the needs of the one outweigh the needs of the many.