Friday, 26 October 2012

The Liverpool Care Pathway


I know there are strong feelings on both sides of the debate about the LCP (about which I have blogged previously, here).

It is a complex issue, and I know people of good will who are strongly supportive of the LCP.   However, I also know two of the signatories of this letter, and when they are worried, I am worried.  They raise serious concerns, which should be properly addressed. 

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Commentary on the Statement supporting the Liverpool Care Pathway

21 October 2012

The Statement supporting the Liverpool Care Pathway from the National End of Life Programme was published under multiple signatories. We have a number of serious reservations and questions about the working of the Liverpool Care Pathway.

1 The statement says, “it is not always easy to tell whether someone is very close to death”.
The fact is that there is no scientific evidence to support the diagnosis of impending death and there are no published criteria that allow this diagnosis to be made in an evidence-based manner. This is even more true of non cancer conditions. This diagnosis is a prediction, which is at best an educated guess. Predictions have been shown to be often in serious error.
There is no evidence that the diagnosis of impending death can be improved by using “the most senior doctor available “, and an actual misdiagnosis of impending death could result in a wrongful death.

2 “The Liverpool Care Pathway …is not a treatment”.
This statement belies what actually happens once a patient is signed up onto the LCP. The fact that morphine, midozelam and glycopyrrolate are prescribed makes the LCP a treatment protocol.

3 “The Liverpool Care Pathway …is…a framework for good practice.”
In the twenty-first century all good clinical practice is evidence based. Good clinical practice has always traditionally involved a close doctor-patient relationship and the management of symptoms in the best interest of the patient, as and when they arise. The LCP is more than a framework. It is a pathway that takes the patient in the direction of the outcome presumed by the diagnosis of impending death. The pathway leads to a suspension of evidence based practice and the normal doctor-patient relationship.

4 “The Liverpool Care Pathway does not….hasten death.”
It is self evident that stopping fluids whilst giving narcotics and sedatives hastens death. According to the National Audit 2010-2011, fluids were continued in only 16% of patients and none had fluids started.
The median time to death on the Liverpool Care Pathway is now 29 hours. Statistics show that even patients with terminal cancer and a poor prognosis may survive months or more if not put on the Liverpool Care Pathway.

Your statement fails to mention the relief of symptoms at all. We think this is a serious omission. The question of consent is not mentioned either.

If as you say, the LCP does not replace “clinical judgement”, and is a “framework for good”, why is it not endorsed by 28% of senior healthcare professionals? (National Audit 2010-2011)

Patients should receive an individual treatment plan according to best evidence based medicine. They should not be deprived of consciousness, but receive such treatment that is aimed at relieving all their symptoms including thirst. Nothing should be done which intentionally hastens death. An individual care plan based on best evidence is preferable to a rigid pathway.

Signed 

Professor P Pullicino
Prof of Neurosciences

Mr J Bogle 
Chairman Catholic Union of Great Britain

Dr P Howard
Chairman Joint Medico Ethical Committee Catholic Union

Dr R Hardie
President Catholic Medical Association

Dr A Cole
Chairman Medical Ethics Alliance 

Dr M Knowles
Secretary First Do No Harm

Mrs N McCarthy
Catholic Nurses Association

Ms T Lynch
Chairman Nurses Opposed to Euthanasia

Mr R Balfour
President Doctors who Respect Human Life

2 comments:

Patti Fordyce said...

Like you, I know two of these signatories, and I know other medical professionals who have publicly expressed concerns. At the very least, it looks to me as if the rolling out of LCP (as opposed to its use in the limited conditions for which it was devised) has led to a coarsening of respect for life at all its stages, as well as an erosion of the sense that an additional few days or weeks at the end of life are worth having.

Part-time Pilgrim said...

I wonder whether it is more a case of the LCP being a lightning conductor for a dimished lack of respect for life that exists already.

I also wonder whether it's ethos of managing the last days of life for the benefit of relatives is the real weakness that allows the lack of respect for life to flourish.

Both tentative suggestions.