Liverpool Care Pathway – A Rogue, By Any Other Name…

What on earth is happening? This is, surely, unthinkable.

Evidently, it is not.

The usual technique of euthanasia is when a doctor administers a lethal injection to a patient. However, when a doctor withdraws life-sustaining nutrition and fluid from a comatose or sedated patient, is this not a form of slow euthanasia?   - Paul Russell

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

Inspectors from the Care Quality Commission (CQC), the NHS watchdog, found nurses sometimes left patients so thirsty that the only way for doctors to ensure they had enough liquid was

to add "drinking water" to hospital medication charts.

The revelation comes in the first reports from the CQC into dignity and nutrition of elderly people treated by the NHS, which reveals a failure to attend to the most basic requirements of care.

The Health Secretary, Andrew Lansley, who ordered the reports, said the failings were "unacceptable". – The Independent

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

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

At Alexandra hospital, inspectors saw meals being served to patients who were asleep. Trays were left out of reach, patients were not offered help to cut up their food and one patient was seen trying to tear a tomato apart with their fingers. Nobody was routinely offered hand washing before or after eating. Although the trust said it offered a choice of dishes, one patient who declined a meal had it taken away without being offered any alternative.

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

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

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

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

What on earth is happening?

Has the CQC uncovered a major breakdown of care across the NHS? Could it be that some tacit design or policy has been revealed? May it be a publicly lauded Pathway of Death at work…?

Life-sustaining nutrition and fluid may be withdrawn from a patient committed onto the Liverpool Care Pathway as a ‘futile’ intervention. Withdrawing life-sustaining nutrition and fluid from a patient will manifest, if these were not already present, signs that are looked for that will confirm a ‘diagnosis’ of encroaching death.

"The issue of whether or not the provision of nutrition and hydration to patients should be considered as medical treatment and, therefore, subject at some level to the discretion of doctors, has received some good press lately.

In Canada, the Euthanasia Prevention Coalition (EPC) fought a legal battle, alongside the family of a comatose patient Mr Hassan Rasouli, to prevent medical staff in a Toronto hospital from removing life-sustaining nutrition and hydration from Mr Rasouli.

An Ontario court subsequently ruled that doctors are required to obtain the consent of either the patient or a substitute decision-maker (such as the patient’s guardian) before withdrawing life-sustaining interventions." – Careful!

The fact that Life-sustaining nutrition and fluid now has to be prescribed places it firmly in the realm of ‘medical treatment' and, therefore, at medical discretion to withdraw.

Is this what is going on?

It could not be such a failing, could it? Such a routine catalogue of catastrophic failure could not occur except by design. Could it…?

If that is the case, it can only be because there is nothing set in place “to ‘drive up’ sustained quality of the living through all the days of our lives!”

Care - full stop - should become a 'quality performance indicator' in support of the governance and performance management framework of all organisations at executive level!

This question really does bear repeating: Why does care of the dying take precedence over care of the living, other than that it is the cheaper option…?

Liverpool Care Pathway – The Underlying Policy

Palliative care is exactly that: it is to ease suffering and pain. It should always be given in that context. 

The Daily Mail reports that family doctor, William Bassett, is before a tribunal to look into his actions in the treatment of his terminally ill patient in 2009.

Every patient is an individual case and every case warrants individual judgement on what measure of response is warranted. To ask whether this doctor administered the dose he administered to end his patient’s pain or to end his patient’s life is not just semantics. It is for the family, the doctor and his peers, and the court to determine what was the case. It is a gross error to make a blanket policy of 'diagnosing' end of life and setting those thus diagnosed on a pathway to death as with the LCP and it is a gross error to cite this case as good reason to support it.

The Liverpool Care Pathway, (LCP), is in widespread use in the UK. It is flawed and dangerous. The Daily Telegraph has referred to it as the Death Pathway. There have been calls from victims’ families to have it banned. The old are particularly vulnerable because many of the so-called signs that are looked for to put a patient on the death pathway, such as frailty and declining mobility, are symptomatic of old-age in any case. In fact, age is one of the factors also taken into consideration in putting the patient on the LCP! Every patient is an individual and deserves that individual consideration of their condition.

As it stands, anyone who falls into the clutches of the proponents of LCP and ticks all the boxes will be given assisted passage into the next world care of the NHS. No doctor has the god-given right to play god. It is a sad irony that, in this case, the doctor would appear to have been paying particular concern to the individual case of his patient and not following some check-box pathway and yet is to be meted dire punishment for that.

The Liverpool Care Pathway began its life as a palliative care pathway within a hospice framework. It is fitting in that aspect. It is necessary in that aspect for those medical personnel to know that they may respond in an effective way to deal with pain and suffering and not be placed in the particular position of this GP.

What began life as a palliative care pathway is now a death care pathway. It is a grotesque caricature of its former self. This Death Care Pathway is being steamrollered into policy throughout the NHS. What, then, has gone wrong? More to the point, why? What agenda or underlying policy is at work? Or is it just a case of 'the Emperor's new clothes'?

These lines are written from a particular position of authority. The NHS donned its hangman's cap and passed death sentence on my dear mother in 2007. Like accounts by other families are regularly reported in the press. Those using this report as an argument in favour of LCP should give careful consideration to what they propose.

Liverpool Care Pathway – The Cheaper Option

"Care of the Dying should become a quality performance indicator in support of the governance and performance management framework of all organisations at executive level"

John Ellershaw, Clinical Lead - LCP, Professor of Palliative Medicine, University of Liverpool,
Director MCPCIL.

Whatever happened to care of the living; should that not, also, be paramount?

About the LCP

The LCP is an integrated care pathway that is used at the bedside to drive up sustained quality of the dying in the last hours and days of life.

LCP Core Document

What is there to ‘drive up’ sustained quality of the living through all the days of our lives; should that not, also, be paramount?

Care - full stop - should become a quality performance indicator in support of the governance and performance management framework of all organisations at executive level!

Why does care of the dying take precedence over care of the living, other than that it is the cheaper option…?

Liverpool Care Pathway – When Routine Is Policy

If something is happening 'routinely', there is the distinct suspicion - it becomes the distinct possibility - it is happening as policy.

One of the country’s leading health campaigners has urged the Scottish Government to urgently tackle the problem of malnutrition of the elderly and vulnerable in the nation’s hospitals, likening the problem to a form of “euthanasia”.
(heraldscotland)


Dr Jean Turner – executive director of Scotland Patients Association (SPA), a GP and former independent MSP – warned that hundreds of patients, particularly the elderly, are languishing in hospital beds undernourished because they are not given help with feeding.


A recent report estimated that 50,000 patients are dying each year in NHS hospitals in a state of malnutrition, which may have hastened their end. (Glasgow Sunday Herald, July 4, 2010).


My mother’s meal was brought in and placed on the bedside table. I took it upon myself to attempt to feed her as they had reduced her to an almost zombie-like state. If I had not been present or had not taken it upon myself to do so, I now ask myself, would anyone have done likewise and attempted to feed her? 


 Removal of feeding and hydration is a protocol of the LCP. A patient unable to feed themselves should not be required to do so against their will…such life-sustaining efforts are futile and even burdensome.


What is going on?

The SPA would call this a form of euthanasia to allow dehydration and malnutrition to develop due to lack of awareness, lack of staffing or carelessness 

When something is happening 'routinely', however, there is the distinct suspicion - it becomes the distinct possibility - that it is happening as policy.

It is difficult and probably wrong to attribute motives to those who deliberately use the combination of sedation and the withdrawal of fluids and nutrition to hasten a patient’s death.

There is little doubt that sedated patients are probably a great deal easier to manage, and death by starvation or dehydration in such circumstances has a predicable time-line, whereas death from the underlying disease may not.

With an ageing population and increasing health care budgets, this sort of “nudge-nudge, wink-wink” approach to reducing costs must be a great temptation.

(News Weekly)

Liverpool Care Pathway - An International Scandal

The time is here; the time is now!

                       Please register your opposition to this madness -                       

Care2 petitionsite        GoPetition        Change.org 

Liverpool Care Pathway – Apology Is Policy

We visit my mother's grave throughout the year, but this 22nd July was four years to the day this dear lady was taken from us. We went to pay our respects, to celebrate her life and to mourn her death at the hands of staff at Caterham Dene Hospital.

There is much explaining to do. This lady was sharp and attentive, as the two and a half Specialist Nurses, Heidi (and her daughter, present on work experience) and Diane, may testify. In Caterham Dene, she was taken off all ongoing medication; they broke her hearing aid and reduced her to a condition of utter stupor. She was so laced with morphine she could neither talk nor order her thoughts to think and died of heart failure. 

Such semi-comatose condition in an elderly person already targets them for terminal diagnosis and conveyance onto the Pathway.

I must clarify for those who have not read previous posts and reiterate for those who have that my mother did not leave this world at Caterham Dene. They waited until the point was reached that death was inevitable and only then decided to telephone Thamesdoc before phoning for an ambulance one hour later upon the non-attendance of Thamesdoc. At least, whatever may be in the written record, an hour elapsed between the two telephone calls they made to me and I actually arrived at East Surrey Hospital A & E before the ambulance, and was present when they brought her in already dead.

The nurses at Caterham Dene had been permitted to administer the prescribed dose of morphine as they thought fit. The Trust had to require Caterham Dene, on the Commission's recommendation, to change this.

Upon our arrival at Caterham Dene, I was taken aside into an office and asked, in the event of anything happening - not that it would – do I want them to move mum to ESH where there are emergency facilities available? What a peculiar question to ask. It makes no sense to ask such a thing except in the context of a policy being set in place at Caterham Dene to let them go and actually help them on their way. As now confirmed by PALS, that is the case, and that policy is called The Liverpool Care Pathway!

At the end of life’s road, what is there up ahead, just around the turning? Should that make a difference? It is enough to know our lives are finite and that we must submit to the call when it comes. In many cultures, the old are afforded a pride of place, not merely as a courtesy but as a right. And when our old ones have attained the age of respect, what then?

When our old ones have outlived their usefulness, cheapened to nuisance and ridicule, borne more as a burden than seen as a resource of experience; when they are fading in body and mind, how comforting to know they may be conveyed to Hospital and Home where the signs may be sought and looked out for to enable a diagnosis of ‘dying’ to be made. How reassuring that their elder years already stand them in good stead for such a diagnosis to be made and that they may be put on this pathway to death and pass peacefully from this world and from our lives, without trauma or too much trouble and inconvenience.

How nice to know that our elders are not pressurised to take their own lives to make it easier for their families and may, instead, be consigned to such a NICE-approved setting.

In many cultures, the old are valued. And in ours?

The fact is that this dear lady's life was not worth a jot. When it became quite clear that we could not obtain justice through the complaints process, we approached a number of solicitors. We were told, quite plainly and simply, that it was all about money. Loss of future earnings was zilch and mum had no dependents. The three days of suffering at Caterham Dene was but a trifle and all she was worth was the cost of her funeral expenses. The case was not financially viable enough to proceed with. It may sound callous, they told us, but that was the way it was. Well, they were honest with us, at least, which is more than can be said of the liars and deceivers in the NHS.

From correspondence:

I also asked you to confirm – or deny – that it is within the remit of the PCT to conceal facts, that is, to lie by omission rather than by commission. I asked that you please respond to this clearly and unequivocally and without benefit of double-talk? I ask you now, once more, is it within the remit of the PCT to conceal facts and to lie?

These questions were not answered; they were simply ignored.

One such solicitor actually confided to us that, in her own experience, this sort of thing is not uncommon in the NHS and a culture has developed of nurses taking it upon themselves to determine quality of life and put people down like pets at a veterinary surgery! She made these comments in response to our account of what occurred at Caterham Dene.

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

Nurses are no longer Angels of Mercy; they are Angels of Death.

But is this ‘diagnosis by death’, euthanasia, or - murder?

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

From BBC News - The alternative to euthanasia? -

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

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

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

Despite an apology he is still not satisfied.

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

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

Despite apologies and assurances that learnings have been taken, we are not satisfied!

Liverpool Care Pathway - The Emperor’s New Clothes

Please: what is going on? A culture of death is spreading like a vile plague through our hospitals and it is met with a quiet acceptance. Like the Emperor’s new clothes, no-one will risk their reputation to speak up and speak out, to question it and hold it to account.

The Care Quality Commission (CQC), the new watchdog body which has succeeded the defunct Healthcare Commission, will not be looking into the matter of the LCP at this time. We are informed that this is because its resources are limited and it is, thus, constrained in what it is and what it is not able to undertake for investigation. In the plight of such circumstances, formulating and following a co-ordinated strategy of investigation in order to better utilise the frugal funds available should be the focus, therefore. Not so.

Instead, the leading lights of the CQC are each pursuing their own 'pet projects' for investigation and the LCP, at present, is not one of them.

As one of these ‘pet’ projects, the CQC has been looking into the neglect of the elderly. At a quarter of hospitals inspected, the Commission found problems with dehydrated elderly patients being prescribed water and others left without being fed.

Patients ‘selected’ to die under the LCP are also dehydrated to death. Food and fluids are withdrawn.

What is going on?

It is imperative that, as a co-ordinated policy in conjunction with its investigations of elder abuse, the CQC should, right here and now, look into End-of-Life care pathways such as The Liverpool Care Pathway!

CLUELESS

The chief NHS regulator has apologised for missing clues to appalling levels of care at Stafford Hospital that developed into the worst health service scandal for a decade. (The Independent Health News)

Cynthia Bower, chief executive of the Care Quality Commission (CQC), said that the West Midlands Strategic Health Authority, which she had headed between 2006 and 2008, had missed warning signs such as complaints from patients about the treatment they received.

The fact is that complaints are routinely treated as frivolous and groundless. The complaints process is ever an endless and arduous journey that few are stalwart enough to withstand and endure to the finish and beyond.

This family has felt itself being ground into submission. And that is what this so-called ‘complaints process’ is really all about: that, somewhere, somewhen down the line, we will quietly go away!

The fact is that, everywhere, we encountered deviousness and artifice in our dealings with those to whom we petitioned in this so-called ‘complaints process’ we must follow to obtain information and resolution to our concerns. What did not begin as a complaint became one in our quest for the truth.

Our experience in this interminable maze of a complaints process was that there is a system in place that sets out to cover the tracks of the wrongdoer at every twist and turn. It is no great wonder to us at all that there are people like Shipman who can, quite literally, get away with murder. Were Dr Shipman’s misdemeanours also raised by family, relatives, friends, and were their concerns also dismissed in like frivolous fashion by PCT and Healthcare Commission alike? Our own experience would suggest this to be the case.

This dalliance, deviousness and artifice persisted even with the Nursing and Midwifery Council (NMC). The NMC had this case for over a year. It is almost as if the NMC exists not to root out the bad crop but, rather, to cover up their misdeeds. That is a disservice to a proud profession and a kick in the teeth for (even though it flies in the face of our own personal experience to say it) the conscientious and caring people on their register.

On 20^th May of this year, we asked:

Please: What is going on?

The NMC will not discipline its registrants where it is considered that they have acted according to policy.

We are not empowered to undertake a general investigation into the performance or conduct of unnamed individuals at a particular institution or organisation where it is said that there have been general failings on the part of that institution or organisation or its staff in general.

What occurred at Caterham Dene was a catalogue of catastrophic events acted out beneath the umbrella of what we suspected to be a tacit policy but which, as it turned out, was a publicly lauded Pathway of Death! So, why was this concealed from us for almost four years?

We are not alone. But If There Is Nothing To Hide, What Is There To hide?