Liverpool Care Pathway – This Clearly Will Not Do

This from the Medical Ethics Alliance -

Medical Ethics Alliance

Letter to BMJ, "Natural Death - is a pathway needed"

Tuesday, 18 September 2012 04:57 Dr A Cole

The Editor BMJ

17/9/12

A conference of the Medical Ethics Alliance entitled “Natural Death - is a pathway needed”, on the 18^th June at the Royal Society of Medicine, attracted a lot of press attention because Prof. Pullicino cast  doubt on the scientific possibility of knowing that death is imminent. One consequence of this has been the number of relatives who have contacted the MEA with highly distressing accounts of deaths on the Liverpool Care Pathway. Amongst the most alarming of which, has been the deaths of elderly people deprived of all fluids for up to fourteen days.

Insufficient attention has been given to a Scottish critique which states;

“A blanket policy of clinically assisted ( artificial ) nutrition or hydration, or no clinically assisted ( artificial ) hydration, is ethically indefensible and in the case of patients lacking capacity prohibited under the Adults with Incapacity ( Scotland ) Act 2000.1

Amongst the symptoms that the LCP lists are - pain, agitation, nausea, vomiting, and dyspnea - but not thirst, though this is one of the most distressing of all symptoms. Nor does moistening the mouth relieve it.

An open letter to NICE calling for central monitoring of complaints from relatives over the implementation of the LCP was not even acknowledged. 2 Blanket assurances that the it conforms with “gold standards” or “quality statements” will no longer suffice. It clearly does not do so.

Dr Anthony Cole

JP FRCPE FRCPCH

Chairman Medical Ethics Alliance

References

1  Adopted  version 12 - Dec. 2010, NHS Forth Valley

2  www.medethics-alliance.org  12/8/12 

Liverpool Care Pathway - An Apology

I don't want to say this -

I shouldn't say this,

and I apologise for saying this -

But I must say this -

They have saved the life of a vile killer;

They have brought him back from the dead -

and they put my dear mum on the Liverpool Care Pathway and killed her.

This is The Sun -

EVIL Ian Brady 'died' after his heart stopped - but medics brought him back to life using a defibrillator, it was claimed today.

Liverpool Care Pathway – An Unhappy Message

It should be a no-brainer, but a recent study actually does confirm this to be the case - Better care means better outcomes.

The study, published in the Lancet, says 

Doctors concede that there is simply not the money to provide such a level of care for all patients.

But they say hospitals need to improve care for “high risk” patients, such as the very old

Doctors say hospitals need to improve care for “high risk” patients, such as the very old.

Here follows an article published in the Scunthorpe Telegraph that is shameful to relate. Is this really 'our' NHS so loudly lauded at the London Olympics?

An elderly lady is referred to hospital by the GP to receive precautionary care. What then proceeds is, unfortunately, not at all extraordinary or anomalous. A similar story of elderly neglect is related in these pages -

She told me that one ‘old girl’ had fallen out of bed. Mum had kept calling for someone to come but no-one came. They were “all stuck in their cubby hole,” she said. I looked across and, by my own observation, they were. Eventually, a nurse had come, apparently, not shocked or concerned, but offended by the nuisance of it.

The neglect this elderly lady suffered demonstrates a lack of even the most basic sense of compassion.

The suffering this lady endured demonstrates a lack of even the most basic palliative care.

The Scunthorpe Telegraph bemoans the "fragmented" provision of 'end of life' care. Actually, it is the very absence of any kind of care!

     
  Scunthorpe Telegraph

Thursday, September 27, 2012
Family complains to Scunthorpe General Hospital over quality of care given to mum 'who died in a place she did not want to be'

A daughter who has raised a complaint with the quality of end of life care her mother was given at Scunthorpe General Hospital has spoken out after a scathing report into mortality rates at the Trust was published.

The damning report, commissioned by the North and North East Lincolnshire Clinical Commissioning Groups, revealed that Scunthorpe General Hospital has one of the worse mortality rates in the country.

COMPLAINT: From left, Hilary Morrison, Nicola Glover and Kaye Farrell. The family has lodged a complaint about the level of care given to Monica Glover at Scunthorpe General Hospital

One of the key problems identified in the report was the fragmented arrangement of Scunthorpe General Hospital's end of life care.

Nicola Glover, of Kirton in Lindsey, said her and her family felt her mother Monica Glover, 80, died "a horrible and undignified death" in Scunthorpe General Hospital on August 10 last year.

Miss Glover claimed her mother endured hours of pain and discomfort before passing away.

"My mum was first admitted into Scunthorpe General Hospital in January 2011," said Miss Glover.

"She had been recovering from a chest infection and her GP wanted to admit her in order to keep check on her progress.

"She was terrified about going in as she was over 20 stone so knew she would need special care.

"When we got to mum's allocated bed we discovered it was not the right type so we put my mum in a chair and waited for a new bed.

"This never came and when I returned the next day my mum was sitting in the same chair.

"She was transferred to another ward and was still not given a suitable bed so was getting very upset by this point.

"She had dressings on her legs for pressure wounds and these had become saturated. They were leaking with excess fluid."

Miss Glover said she was upset by how long it took to give her mother a bed.

She said: "We felt disgusted with her care and discharged her."

Miss Glover said her mother spent the next six months in and out of Scunthorpe General Hospital.

Miss Glover said: "My mum was admitted into hospital for the final time on August 1 with a urine infection.

"She quickly developed sepsis and renal failure and she deteriorated very rapidly.

"It was very upsetting for the whole family.

"On August 9 we were told by an intensive care doctor that nothing could be done.

"I don't think the end of life care system was put in quickly enough. I believe she died in an undignified manner in a place she did not want to be in.

"I don't think mum received the best care.

"We are seeking legal advice into the case."

Wendy Booth, trust director of clinical and quality assurance, said: "The family of Monica Glover have made a formal complaint which we have fully investigated and responded to.

"We have also met with the family on July 23, 2012 to further discuss their concerns.

"We are still waiting to hear back from the family as to how they would like to proceed with the complaint."

'REPORT SENDS OUT AN UNHAPPY MESSAGE'

The chairman of North Lincolnshire Council’s Health Scrutiny Panel said she was “disappointed but not surprised” with the findings of the mortality report.

Councillor Jean Bromby said at the group’s latest meeting that they had been aware of the figures published in the report for just under a year.

She said: “We have met with members of the health board and they have been very defensive.

“We have been waiting for the report from Transforming Health with baited breath and are disappointed but not surprised with the outcome.

“We have asked for a meeting with the chief executive and will be asking her a lot of questions.

“We want to work with everyone to try and improve the figures and need to support the relevant people.

“The whole council needs to be behind this report and the message we need to get out is support. The report is an unhappy message to send to the population.”

The panel’s next step is to conduct a meeting with chief executive of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Karen Jackson on October 8.

Board members have set up another visit to Scunthorpe General Hospital to discuss patient care.

REPORT FINDINGS

The report into increased mortality rates has highlighted that staff who were interviewed did not feel a high enough priority was given to end of life care.

Some of the issues raised about end of life care in the report are the lack of specialist consultants and poor access to specialist support and GPs out of hours.

The report also identifies how the hospitals have insufficient resources such as palliative care and Macmillan nurses.

The report identifies poor access to hospice facilities including lack of bed and out-of-hours care.

In particular it was identified that the use of gold standards frameworks, a system to optimise the care for patients nearing the end of life, and the Liverpool Care pathway (LCP), a model used to sustain quality of the dying in the last hours and days of life, throughout is not consistent and there is a lack of supporting patients in their preferred place to die.

The report concludes: “Further work is needed to use data rather than rely on perceptions about end of life care.

“End of life care is fragmented and it is hard to establish a complete picture of provision, gaps, priorities and progress.”

Of the report, a spokeswoman for Who Cares, an independent local health and social care watchdog, said: “The Summary Hospital Mortality Ratio (SHMI) published by Northern Lincolnshire and Goole Hospitals Foundation Trust (NLaG) was one of the highest such ratios in England. This is obviously of great concern to Who Cares. While we are encouraged by the measures NLaG has and will be implementing to address this serious issue, their progress will be closely monitored by Who Cares.”

This elderly lady 

"was terrified about going in as she was over 20 stone so knew she would need special care."

The study referred to above confirms that better quality of care means better outcomes. Had this lady received the attentive care her family - certainly, her GP - had expected she would receive, would the outcome have been a very different one?

The outcome was, tragically, that she died in a place she did not want to be!

Liverpool Care Pathway – Welcome To The 21st Century

Welcome to the 21st century. The following article from the New York Post has major ramifications in regard to the practice of death pathways (euthanasia by stealth) and of assisted suicide, both of which are being shunted along with almost irrevocable enthusiasm by those with influence and with power.

Anna Soubry is the newly appointed Under-Secretary of State for Health. Here is the MailOnline -

Ms Soubry said in an interview at the weekend: 'I think it’s ridiculous and appalling that people have to go abroad to end their life instead of being able to end their life at home.

'The rules that we have about who we don’t prosecute allow things to happen but there’s a good argument that we should be a bit more honest about it.'Asked about Ms Soubry’s comments, Downing Street today hinted that Parliament could look again at the issue.

And here is thisisNottingham  -

Broxtowe MP Anna Soubry calls for 'evolution' of the law on assisted suicides

The New York Post article should be read in context with the following which may be found in these pages -

Liverpool Care Pathway - Nazifying The NHS

People killed by euthanasia in Belgium are having their organs harvested for transplant surgery, a new report has revealed.

Eurotransplant, a co-ordination group for transplants in Austria, Belgium, Croatia, Germany, Luxembourg, the Netherlands and Slovenia, is now devising elaborate protocols for ‘organ donation and transplantation after euthanasia’. Dr Peter Saunders, of Care Not Killing, an umbrella group of more than 50 British medical, disability and religious charities opposed to euthanasia, said he was shocked by the report.

‘I was amazed at how nonchalantly the issue was dealt with as if killing patients and then harvesting their organs was the most natural thing in the world,’ he said.

The New York Post article should be read in context with the following which may be found in these pages –

Liverpool care Pathway – A Moral Minefield

Once again, we are treading that moral minefield of the ‘life unworthy of living’ and the decision with purposeful intent to terminate a life. The gaining of acceptance of this concept led, in the 20^th century, from sanatorium and clinic to concentration camp and gas chamber and world war.

The Netherlands and Belgium have provided the 21^st century a window for observing the practice of euthanasia for twenty years. Even though the practice is legal, there has been a demonstrated preference by MDs for the practice of terminal sedation. An associated organ donation program has produced a harvest organised on a conveyer-belt style unprecedented for its medical efficiency since the days of the Third Reich.

This is from openPR 

Transplantation of lungs: recovered from donors after euthanasia

Press release from: Pabst Science Publishers 

Donors after cardiac death have increasingly provided organs for lung transplantation in Belgium. Between 01/2007-12/2009 in Leuven 17 isolated lung transplantations were performed from cardiac death donors, including four after euthanasia, Dirk van Raemdonck and colleagues (Leuven) report. "All donors expressed their wish for organ donation once their request for euthanasia was granted according to Belgian legislation. All donors suffered from an unbearable non-malignant disorder." One recipient died from a problem unrelated to the graft. The other three patients are still alive - in a good condition.

The weak and the vulnerable are going to be pressured to do the right thing and die. That isn't how it will start out but that is how it will end up.

Organs taken from patients that doctors were pressured to declare brain dead: suit

• By JAMIE SCHRAM Police Bureau Chief
• Last Updated: 7:43 AM, September 26, 2012
• Posted: 1:17 AM, September 26, 2012

The New York Organ Donor Network pressured hospital staffers to declare patients brain dead so their body parts could be harvested — and even hired “coaches” to train staffers how to be more persuasive, a bombshell lawsuit charged yesterday.

The federally funded nonprofit used a “quota” system, and leaned heavily on the next of kin to sign consent forms when patients were not registered as organ donors, the suit charged.

“They’re playing God,” said plaintiff Patrick McMahon, 50, an Air Force combat veteran and nurse practitioner who claims he was fired as a transplant coordinator after just four months for protesting the practice.

Dennis Clark

Patrick McMahon

The suit, filed in Manhattan Supreme Court, cited four examples of improper organ harvesting.

In September 2011, a 19-year-old man injured in a car wreck was admitted to Nassau University Medical Center. He was still trying to breathe and showed signs of brain activity, the suit charged.

But doctors declared him brain dead under pressure from donor-network officials, including Director Michael Goldstein, who allegedly said during a conference call: “This kid is dead, you got that?” the suit charged.

The patient’s family consented to have the organs harvested.

“I have been in Desert Storm, Iraq and Afghanistan in combat. I worked on massive brain injuries, trauma, gunshot wounds, IEDs. I have seen worse cases than this and the victims recover,” McMahon told The Post.

That same month, a woman was admitted to St. Barnabas Hospital in The Bronx still showing signs of life, the suit said.

She had a kidney transplant earlier in life and network officials used that to pressure her daughter into giving consent.

“They say to her, ‘If you give us permission we will use your mother’s organs and we will help many, many people who need them,’ ” he said.

McMahon’s objections were ignored by a neurologist, who declared her brain dead — and her organs were harvested, according to the suit. McMahon even claims he tried to get a second opinion.

A month later, a man was admitted to Kings County Hospital in Brooklyn, again showing brain activity, the suit said. McMahon claims his protests were again blown off by hospital and donor-network staff, and the man was declared brain dead and his organs harvested.

In November 2011, a woman admitted to Staten Island University Hospital after a drug overdose was declared brain dead and her organs were about to be harvested when McMahon noticed that she was being given “a paralyzing anesthetic” because her body was still jerking.

When he objected, another network employee told hospital personnel McMahon was “an untrained troublemaker with a history of raising frivolous issues and questions,” the suit charged.

“I had a reputation for raising a red flag,” he said.

In order to harvest organs, the network needs a “Note” — an official declaration by a hospital that a patient is brain dead — and consent from next of kin.

The network hired marketing and sales professionals to “coach” workers to tailor their pitches based on the family’s demographics, said the suit, filed by McMahon’s lawyers Michael Borrelli, Alexander Coleman and Bennitta Joseph.

The suit said that on Nov. 4, McMahon told Helen Irving, president and CEO of the network, “one in five patients declared brain dead show signs of brain activity at the time the Note is issued.”

Irving, the suit said, replied: “This is how things are done.”

Network spokeswoman Julia Rivera said she hadn’t seen the suit, but noted that only doctors can declare a patient brain dead.

She called McMahon’s claims of a quota system “ridiculous. There are no quotas.”

A Staten Island University Hospital spokeswoman declined comment. Reps for the other three hospitals could not immediately be reached.

Additional reporting by Bob Fredericks

Liverpool Care Pathway – Debunked!

A 'Consensus Statement' has been drawn up and signed by some 20 organisations which seeks to debunk “misconceptions and often inaccurate information” about end-of-life Care Pathways such as the LCP. This follows here -

Consensus Statement: Liverpool Care Pathway for the Dying Patient (LCP)

Published misconceptions and often inaccurate information about the Liverpool Care 
Pathway risk detracting from the substantial benefits it can bring to people who are dying 
and to their families. In response to this we are publishing this consensus statement to 
provide clarity about what the Liverpool Care Pathway is - and what it is not.

The hospice movement in the UK is famous around the world for looking after dying people 
with dignity and skill. Since the late 1990s, the Liverpool Care Pathway has been helping to 
spread elements of the hospice model of care into other healthcare settings, such as 
hospitals, care homes and people’s own homes.
  
The Liverpool Care Pathway: 

 Requires staff ensure all decisions to either continue or to stop a treatment are taken in the best interest of each patient. It is not always easy to tell whether someone is very close to death – a decision to consider using the Liverpool Care Pathway should always be made by the most senior doctor available, with help from all the other staff involved in a person’s care. It should be countersigned as soon as possible by the doctor responsible for the person’s care.

 Emphasises that people should be involved in decisions about their care if possible and that carers and families should always be included in the decision-making process. Of those who responded as part of the evaluation, 94% said that they had been involved (National Care of the Dying Audit – Hospitals, MCPCIL/RCP, 2011).

 Relies on staff being trained to have a thorough understanding of how to care for people who are in their last days or hours of life.

 Is continually evaluated in all the places where it is in use.

The Liverpool Care Pathway does not: 

 Replace clinical judgement and is not a treatment, but a framework for good practice.

 Hasten or delay death, but ensures that the right type of care is available for people in the last days or hours of life when all of the possible reversible causes for their condition have been considered.

 Preclude the use of clinically assisted nutrition or hydration - it prompts clinicians to consider whether it is needed and is in the person’s best interest. GMC guidance (2010) provides specific information regarding this issue.

In response to a question asked in the House of Lords on 20th June 2012 the Parliamentary 
Under Secretary of State for Health, Earl Howe, said “The Liverpool Care Pathway has 
sometimes been accused of being a way of withholding treatment, including hydration and 
nutrition. That is not the case. It is used to prevent dying patients from having the distress of 
receiving treatment or tests that are not beneficial and that may in fact cause harm rather 
than good.” 

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).   

We support the appropriate use of the Liverpool Care Pathway and make clear that it is not 
in any way about ending life, but rather about supporting the delivery of excellent end of life 
care.

Liverpool Care Pathway Consensus Statement - September 2012

The reality of the LCP in action is shared by a new doctor on the 'coal face' at Princess Royal Hospital. You may read his experience here -

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 new 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 new 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 new 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 new doctor, from his account, considers his individual patient. Is the new doctor learning what Max Pemberton calls the 'art' of medicine? One hopes so. It would seem so. Then, there is hope yet.

Here is a new 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 new 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 by the absentee consultant. 

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

Professor Pullicino

The Liverpool Care Pathway "provides guidance on anticipatory prescribing of medications and discontinuation of inappropriate interventions." These "inappropriate interventions" will also include removal of prescribed medicines which have previously maintained the patient's stability.

Medical practice is always only an assessment of outcomes, a prognosis that continually shifts. Observation is everything and responsiveness to that observation is paramount.

This is MAX PEMBERTON in The Telegraph:

Liverpool Care Pathway: The decision to withdraw treatment from a patient is an incredibly complex one

Finger on the pulse His grandfather's illness gives Max Pemberton an insight into the perils of tick-box medicine

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.

Emphases are mine throughout.

The Liverpool Care Pathway is a set of protocols that impose their own definition of what is the “best interest of each patient”.

In the absence of competence on the part of the patient this “best interest” is always determined by the doctor.

So, what is ‘best interest’?

“Clinical judgement” is also guided by these protocols set by the pathway. Pre-emptive prescribing is recommended. This already presupposes that the prognosis is not in error.

Evidencing and recording is paramount and takes precedence; evidencing and recording becomes the actual care and guides the practitioner along the pathway.

A “dignified death”? Families who have personal experience of their loved ones being placed on the LCP might question what that means. It is not a hysterical mass-media reporting this but the unheard and disregarded voices on bulletin boards and on forum pages.

This 'Consensus Statement' is only that: a consensus of opinions hamstrung together by the diverse parties involved who have agreed to release it. It is their consideration of what a death pathway 'should' look like.

On a final note, is it really necessary to comment that there is this focus, bordering on obsession, on care of those 'diagnosed' or deemed to be dying and that this is almost at the expense of care of those yet living?

To have a good death, yes. But to have a good life, yes, yes, and a thousand times, yes!

Are we yet to see a Consensus Statement on this?

I suppose it all comes down to cost.