Liverpool Care Pathway - End Of Life Wishes And The Midazolam Legacy

Care of the ‘dying person’ was always about care for the person observing the ‘dying person’, not the ‘dying person’.

‘How people die remains in the memory of those who live on’ Dame Cicely Saunders Founder of the Modern Hospice Movement

- End of Life Care Strategy

And yet a perverse obsession with death and dying perverted even that.

Command control distorts and does not address issues.

And the end of life care plan rolled out by the State that imposed a pathway to death will forever remain in the memory of those who live on!

The pathway fast became a highway that no-one could challenge without ridicule being heaped upon them. The LCP was the 'Little Red Book' that Chairman Ellershaw's obsessive followers imposed, word for word, line by line, verse and chapter upon the 'dying persons' they had diagnosed.

When is a Death Panel not a death panel?

When it’s an Ethics Committee or 'multi-disciplinary team'...

ACDs are supposed to be about recording wishes so that at a moment in time when it may no longer be possible that those wishes may be expressed because of the plight or predicament of the person who, through forethought, has wished them expressed, they will be respected.

A dodgy pro-euthanasia ‘charity’ has been working hand-in-glove with Age UK to promote ACDs and sign up vulnerable people to them.

However, ‘respect’ for wishes has always been about respect for dying wishes, not living wishes.

Three years ago, a Liverpool family took a Hospital ‘death panel’ to court to obtain a ruling that Mr. David James should continue to receive life-sustaining treatment. The family won the High Court judgement.

Not to be so easily brow-beaten, the ‘death panel’ sought a counter appeal against the decision – and won.

Mr. David James lost his fight for life and passed away in the early hours of New Year’s Eve, 2012. His family called it ‘legalised murder’.

Almost three years later to the day, a Houston man, Mr. Chris Dunn, has lost his fight for life following a legal battle to retain life-sustaining treatment.

That is ‘life-sustaining’, not ‘life-supporting’.

The US Constitution has been disparaged as “a charter of negative liberties,” which “says what the states can't do.”

It is, indeed, a Charter of negative liberties, but also a Charter of positive rights. There is a positive right to life and liberty.

In recent years, on both sides of the ‘pond’, this has been turned about-face and on its head. There is now a 'right' to death. A death cult has ruled supreme.

This is Fox News Insider –

In the picture, Chris Dunn is videoed pleading for his life.

To stop them from withholding life-sustaining treatment, his mother challenged the hospital in court.

“There’s a statute in Texas that allows hospitals to form a nameless, faceless committee and make a decision that they want to terminate life-sustaining care,” said Joe Nixon, an attorney from the Texas Right to Life organization.

Yet, in the video above, Dunn is seen nodding and putting his hands together to pray when he’s asked whether he wants to live.

The legislation is the Texas Advance Directives Act.

This is Houston Chronicle –

Joe Nixon, the Dunn family's attorney, said the hospital sought guardianship over the sick man on Dec. 3, hours before the court was to deliberate on a family petition seeking to stop the hospital from discontinuing care. While no formal injunction was issued, the judge mandated that the hospital continue life-sustaining care while the guardianship issue was resolved, Nixon said.

A provision of the Texas Health and Safety Code, which outlines procedures for advance directives in life-threatening medical situations, calls for a review by ethics or medical committees when an attending physician refuses to honor a patient's advance directive or a health care or treatment decision made by or for the patient. If the committee, in essence, determines requested care is futile, an effort can be made to transfer the patient to another facility. After 10 days, the physician and hospital are not obligated to continuing life-sustaining treatment.

In Dunn's case, the hospital committee was composed of physicians, nurses, social workers, chaplains and a medical ethicist,

In a Dec. 2 video, Nixon asked Dunn, whom he described as "conscious and alert" whether he wanted to continue to live. Dunn nodded slightly and made a gesture indicating prayer.

abc 13 Eyewitness News follows up –

The hospital told Dunn's family this week that it would soon stop his life-sustaining treatment. The family refused to accept the decision.

According to Texas Right to Life, Methodist continued life-sustaining care for Chris and he died this morning around 6:30am of natural causes. His attorneys feel they still have grounds to challenge the state law that allows hospitals to discontinue life sustaining treatment at their discretion.

Dunn's mother, Evelyn Kelly, shared this statement: "Chris's family and I are grateful for all of the prayers, kind notes of encouragement, and support we have received from around the world. We would like to express our deepest gratitude to the nurses who have cared for Chris and for Methodist Hospital for continuing life-sustaining treatment of Chris until his natural death. Chris's health battle has now ended, but I intend to continue the fight against this horrible law. No family should have to fight for the Right to Life of their loved one."

The provision of ‘dignity in dying’ has been a long term obsession, adopted as slogan and title by the merchants of death who peddle death as a treatment in place of cure. Before signing up to an ACD, however, do consider that those ‘tubes’ may be there to provide continued life-sustaining care.

The Hippocratic Oath requires the physician to not harm, to treat, provide care and alleviate discomfort and this is without differentiation of whether ‘living’ or ‘dying’ but always to the person as a person requiring the physician's attention.

In the treatment of the ‘living person’ it is as much a priority to address symptoms and manage pain as it is in the ‘dying person’. 

There is always recognition of the limits of the physician's skill and ability to treat but the context is always the person.

The use of benzodiazepines in palliative care is examined in Palliative Medicine –

Hoskin and Hanks reported on the medication received by 158 patients at the Royal Marsden Hospital, a specialist oncology hospital. A total of 39% were prescribed anxiolytic drugs, presumably benzodiazepines, although this was not further described. Most recently, Sykes and Thorns reviewed the use of sedative drugs, including benzodiazepines, in the last week of life and found that 82% of patients received midazolam on at least one occasion. Building on this work, we aimed to explore more widely the use of benzodiazepines in our unit. Although terminology varied between staff, a diagnosis of anxiety or terminal restlessness was most likely to prompt the administration of benzodiazepine.

It might be argued that benzodiazepine prescribing represents a medicalization of distress, a ‘quick fix’ to deal with distress which might, if picked up early, have been tackled by listening to concerns, providing reassurance, and so on. We did not examine the extent to which our group received formal psychological support. Whether or not this is provided, there are some situations where the approach of death is so distressing that only pharmacological assistance appears practicable, although more research is needed on determining the relative appropriateness of drug and non-drug approaches at different stages in the patient’s journey. Nonetheless, in patients who are well enough, psychotherapeutic approaches, such as cognitive behavioural therapy, are successful comparative to the use of drugs and can have an impact on anxiety in as little as one session, although still at the cost of greatly increased staff time compared with the use of drugs.

The advent of palliative care played an important role in widening the appropriate use of opioid analgesics. The relatively high level of benzodiazepine prescriptions in our study suggests that the same is happening here. Protocols for the use of benzodiazepines in other healthcare settings emphasize the need for short courses, low doses and the avoidance of ‘as required’ prescriptions. There is little evidence for long term efficacy, but with a median stay under the hospice’s care of just over three months, relatively few of our patient group could be said to have long term benzodiazepine use unless they had been taking this class of drug prior to hospice referral. Indeed, the fact that half of all benzodiazepine use was within the last three weeks of life and by a parenteral route implies that the patient group under consideration here is different from those with which usual guidance for benzodiazepine use is concerned. The relevance of benzodiazepine protocols to palliative care settings remains unclear. Of course there needs to be awareness of potential problems arising from benzodiazepine prescribing. Although in people with a short prognosis, concerns about dependence are much reduced, benzodiazepines have a number of adverse effects, including falls, drowsiness, dizziness and impaired cognitive function.

Under the palliative regime and the LCP, did ‘dying’ become a medicalised ritual to provide a cosmetic death?

- Journal of Pharmacy Practice

Opioid analgesics are the leading class of prescription drugs that have caused unintentional overdose deaths. Benzodiazepines when taken alone are relatively safe agents in overdose. However, a 5-fold increase in deaths attributed to benzodiazepines occurred from 1999 to 2009.

The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression.

The combination prescribing of benzodiazepines and opioid analgesics commonly takes place in palliative care.

Naloxone is not carried in Just in Case Boxes. 

But if you have been diagnosed as dying anyway that should not be a matter for consideration, perhaps.

Perhaps.

The benzodiazepine Midazolam is commonly used to control breathlessness and anxiety. If this is being achieved through respiratory depression in combination with opioid analgesics that may be a cause for concern and confirm LCP victims relatives' suspicions...

"Due to the MISDIAGNOSIS my darling had a DNR order placed within her notes and beneficial respiratory medication and anticoagulation was withdrawn and a Morphine syringe driver, with Midazolam and Cyclizine was surreptitiously used to hasten death."
- Age UK Blog

Midazolam creates the appearance of calm, as befits the desire of palliative care that loved ones may only have good memories of their loved one's passing.

However, within that shell of exterior calm, there may be turmoil and anguish...

Liverpool Care Pathway - "No Midazolam"

This is Journal of Clinical Practice –

The Liverpool Care Pathway LCP) for the dying patient is a UK care pathway covering palliative care options for patients in the final days or hours of life; it has recently been recommended for decommission in the UK following an independent review. The pathway was widely imple­mented in UK hospitals in part because of governmental financial incentives. One of the criticisms of the LCP included reports of the rapid escalation to continuous infusions of sedatives in patients who then became quickly unconscious and unable to communicate.

The article discusses  the risks of Midazolam infusions and interrupted hydration.

The interruption of oral hydration (due to sedation) or through the cessation of artificial hydration is likely to significantly increase the plasma levels of Midazolam and its metabolites with potentially adverse consequences.

Elderly patients appear particularly sensitive to Midazolam-induced respiratory depression and arrest, especially in combination with opioids which are commonly co-employed. Dying or critically ill patients may also have abnormally low albumin blood levels leading to greater sensitivity to Midazolam.

In human liver microsomes, midazolam is exten­sively metabolized to two primary metabolites, 1'-hy­droxymidazolam (l'-OH MDZ) and 4-hydroxymidazolam (4-OH MDZ). However, the hydroxylated metabolites can he further metabo­lised and are excreted from the body as glucuronic acid conjugates. Urinary analysis has revealed that 60-80% of the administered dose is eliminated as 1'-hy­droxymidazolam glucuronide (I'OH MDZ glucuronide). The biotransformation products of midazolam contribute to the net pharmacological effect of mi­dazolam by activity at the benzodiazepine receptor: I'-OH MDZ has 63% of the potency of midazolam; however, the effect of 1'OH MDZ glucuronide is usually neglected because of its lower potency (6%) and normally rapid excretion.

Seemingly moderate doses of sedative drugs, delivered by continuous infusion combined with interruption of hydration could produce unexpected over-sedation and death.

Version 12 of the LCP provides generic medica­tion recommendations for local providers to imple­ment in accordance with their governance frameworks. Typically, patients who have had two or three as required' doses of 2.5-5 mg ot midazolam SC. tor restlessness or agitation are escalated to midazolam by continuous infusion by syringe driver.
 Other drugs used alone or in combination with midazolam tor this indication included levomepromazine and haloperidol.

As long ago as 1995 when the LCP was yet a glint in Ellershaw’s eyes and trials were still ongoing at Gosport War Memorial, rehydration was being discussed as whether appropriate in hospice...

Patients who are in the last few days of life are often too frail to take oral fluids and nutrition. This may be due entirely to the natural history of their disease, although the use of sedative drugs for symptom relief may contribute to a reduced level of consciousness and thus a reduced oral intake. Rehydration with intravenous (i.v.) fluids is the usual response in acute care settings, whereas the hospice movement has often argued against this approach. The issues are complex and involve not only physical, psychological and social concerns, but also ethical dilemmas. A review of the literature gives conflicting reports of the physical discomfort that may be attributed to dehydration in dying patients. There are many confounding variables, including the concomitant use of antisecretory drugs, mouth breathing and oral infection. It remains unproven whether i.v. fluids offer symptomatic relief in this situation. Hospice doctors are concerned that the use of i.v. fluids gives confusing messages to relatives about the role of medical intervention at this stage in a patient's illness. A drip may cause a physical barrier between a patient and their loved one at this important time. 
- PubMed

Relatives who were made to stand helplessly by and watch their loved one dehydrated to death might say otherwise.

Additional reading -

Liverpool Care Pathway - A Crime Has Been Committed

Liverpool Care Pathway - In Whose "Best Interests"?

Liverpool Care Pathway – An Invasive Pathway

Liverpool Care Pathway – A Life Evaluation

Liverpool Care Pathway - The Final Countdown

An additional word:

'The burdens of treatment are great indeed but must be weighed against the benefits of continued existence'
- Mr Justice Jackson

And some final words...

Liverpool Care Pathway - Semantics, Semantics, Semantics

Liverpool Care Pathway - Be Not Disarmed By The Caring Smile

Liverpool Care Pathway – A Gathering Momentum

Liverpool Care Pathway - By Intrusion And By Stealth