The Liverpool Pathway and euthanasia

It might be better if we called the Liverpool Pathway what it actually is: euthanasia.

The combination of morphine and dehydration is known to be lethal, and four-hourly reassessment is pointless if the patient is in a drug-induced coma. No one should be deprived of consciousness except for the gravest reason, and drug regimes should follow the accepted norms as laid down in national formularies.

Agreed, there is a delicate line between the opiate doses needed to alleviate the pain of certain diseases and the opiate doses which kill.

But dosing them up and dehydrating them is over on the other side of that line, no?

the pathway, which is implemented in up to 29 per cent of hospital deaths.

Note that this is not about do not resusitate: we have a deliberate and specific course of action which is intended will lead to the death of the patient.

It\’s very difficult indeed to call this anything other than euthanasia.

And, you know, killing people is wrong.

44 comments on “The Liverpool Pathway and euthanasia

  1. “It might be better if we called the Liverpool Pathway what it actually is: euthanasia.”

    In cases where doctors have not obtained consent, we have a different term for it: murder.

    Start prosecuting them.

  2. And to think people laughed at Sarah Palin when she made her comments about Death Panels.

    Yet here we are, with the nice NHS, causing about a third of all people who die in hospitals in the UK to die from thirst because doctors have decided to kill them.

    Prosecution is not enough.

  3. And where they have obtained consent, don’t prosecute them.

    If someone wants to die without pain and without discomfort a short while before their time then why should doctors prolong their life.

  4. SBML wins it. If I’m ever sick enough to be eligible for the Liverpool Pathway, I bloody well hope it’s still in use at the time. No interest *whatsoever* in being kept alive in horrible pain for an extra fortnight when a painless morphine coma is on offer.

    Informed advance consent is important, and is already required. If you’d rather suffer, that’s your call. But don’t tell me that my end of life has to be any more horrible than otherwise just because your weird principles are offended by an informed choice taken by me and my doctors.

  5. johnb: “Informed advance consent is important, and is already required. “

    And the report claims that doctors are not always securing it.

    You can have whatever death you want. But you don’t get to mandate it for everyone else.

  6. SBML: “And where they have obtained consent, don’t prosecute them.”

    Agreed. But that bit’s not the sticking point, is it?

  7. john b – “If I’m ever sick enough to be eligible for the Liverpool Pathway, I bloody well hope it’s still in use at the time. No interest *whatsoever* in being kept alive in horrible pain for an extra fortnight when a painless morphine coma is on offer.”

    Well that should be a choice, perhaps, for the patient. But that is not what we are talking about. We are talking about people dying of thirst well before their time. So why not offer the third option – someone is put into a drug induced coma and then left to die of whatever it is that is killing them? Hastened by the drugs perhaps but not caused by a lack of care.

    “Informed advance consent is important, and is already required.”

    No it is not. This is being used in half of all cases where the patient and their family has not even been told. That is one in seven deaths. That is not a trivial issue.

    “If you’d rather suffer, that’s your call.”

    The other option is not suffering. It is being given enough morphine as needed. Just not left to die of thirst. The only reason for hastening the death is to free the bed. And frankly I am happy enough if you want to die early to give the bed to someone else. But I don’t think doctors ought to be making those decisions without the consent of the patient and their families.

    “But don’t tell me that my end of life has to be any more horrible than otherwise just because your weird principles are offended by an informed choice taken by me and my doctors.”

    No one is suggesting that. Not that insisting doctors don’t kill people deliberately is weird.

  8. JuliaM: No, it’s not the point, but if some doctors are effectively commiting euthanasia under some polticially correct term (cf. collateral damage for murdering civilians) then accept that it is happening and properly regulate it. Allow people who want to die and need some help to do so without scaring those who want to provide the help with threats of prosecution. Statements in advance of the act logged away somewhere to show that everyone involved have all consented and are fully aware and have exhausted all other avenues should be enough.

    Sometimes killing people is right, but only when the person wants to die.

  9. SadButMadLad – “(cf. collateral damage for murdering civilians)”

    Sorry but collateral damage is not murdering civilians. It is, as it says, causing unwanted and unintended loss due to otherwise legitimate acts. There is no intent to kill and hence no murder.

    “then accept that it is happening and properly regulate it.”

    How do you properly regulate killing other people? How can you stop the next Shipman claiming it was done with the patients’ consent?

    Are you going to apply this to every act that is presently illegal?

    “Allow people who want to die and need some help to do so without scaring those who want to provide the help with threats of prosecution. Statements in advance of the act logged away somewhere to show that everyone involved have all consented and are fully aware and have exhausted all other avenues should be enough.”

    The Netherlands tried this. It has not worked. Once society changes, you can’t go back. Once we have accepted that abortion is kind of cool, everyone wants one and no one can even see what the purpose and moral objections to the law meant at the time. Once we have accepted that gambling is fine, there is no practical limit. Nor is there any reason to think so with euthanasia either. As the Dutch are showing.

    “Sometimes killing people is right, but only when the person wants to die.”

    So it is fine to advertise for someone to eat on the internet as long as they voluntarily consent?

  10. SadButMadLad (#3) – dehydration is very far from painless.

    I’m told if you want to ease someone out nicely, you just up the morphine levels to keep the pain away (”The King’s life is moving peacefully toward its close.” – George V or VI?) and it’s done.

    But that’s not quite quick enough for some doctors, and needs more effort on their part.

  11. If I am to be bumped off, please inform the medics that I’ll be happy with the morphine but I don’t want the deprivation of water. Thank you.

  12. “And, you know, killing people is wrong.”

    Of course, Timmy. But it’s easy enough to demonstrate that killing someone is not the worst thing you can do to them, so that leaves plenty of room for killing someone to be the least-worst option morally.

  13. Someone you love is in a coma, at least partly because of the high doses of intravenous diamorphine they are being given to control their pain. They are sleeping peacefully and they’re very unlikely to wake up. You can, probably, keep them alive longer by injecting them with fluids, and perhaps for longer still by feeding them through a tube. Is that what you want to do?

    The Liverpool Care Pathway has been developed to provide a painless and dignified death for terminal patients. There seems to be no better pathway, which is why the LCP is widely used.

    I don’t doubt that there are cases of abuse. Let’s seek to prevent them.

  14. TLC>

    Simple enough – I did mean by logical argument, though, rather than an actual demonstration.

  15. My father died rather like this last year. He wasn’t in a coma, just incapable of feeding himself and, latterly, of swallowing when fed. Multiple dementias had deprived him of all involvement with the world except occasional distress. He could have been kept alive only by increasingly aggressive treatment and tube feeding. Instead, he died peacefully.

    By then, anything else would have seemed unreasonably cruel.

    But he didn’t request this approach in a living will and had been incapable of giving meaningful consent for a couple of years, and of any communication at all for about a year.

    We couldn’t ask him, we just had to try to do the best we could for him. Yes, that meant letting him die.

  16. But Peter, you can see the potential for NHS staff or unscrupulous relatives to hasten the end of inconvenient patients under the cloak of ‘kindness’, can’t you?

    And what’s really so ‘kind’ about it? If I take a pet to the vets for euthanasia, it’s done there & then. I’m not advised to dehydrate it to death under sedation because that would be – rightly! – considered animal abuse.

    If doctors really thought this (hastening death) was the right thing to do, then why not be honest about it, do it properly and rigorously police it.

  17. Jesus.

    Of course everyone can see the potential for abuse.

    Do / can the benefits outweigh the risks?

    If doctors really thought this (hastening death) was the right thing to do, then why not be honest about it, do it properly and rigorously police it.

    Because they’ll risk a murder charge if they say, “hi! I killed a guy!”

  18. Someone you love is in a coma, dying. You have decided to take no further steps to prolong their life. Do you want to take the decision to knock them on the head, or would you prefer to let nature peacefully take its course?

    Alternatively, you are a doctor or a nurse. Do you want to be in the business, even if it were legal, of actively killing patients?

  19. Julia, I’m not certain this gets used unscrupulously but agree it would be far better for it to be fully in the open.

    You’re right that doing this to an animal would be considered cruel, but then euthanasia is legal with animals. It’s ironic that the consequence of giving extra protection to human life is this extra cruelty sometimes.

  20. PaulB: “Alternatively, you are a doctor or a nurse. Do you want to be in the business, even if it were legal, of actively killing patients?”

    Haven’t they already crossed that line with:

    A) abortion, and
    B) doctors present in death penalty cases?

  21. Who gets the benefit,…

    The patient who wants to be killed in particular circumstances.

    … and who takes the risk..?

    Patients who don’t want to be killed.

  22. JuliaM:

    A) in an abortion, the patient is the pregnant woman. Doctors and nurses who participate in abortions – there is a right in the UK not to do so – take the view that a fetus is not a person.
    B) yes, but few doctors choose to take part. Notably, the American Medical Association has ruled that “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution”, albeit it takes no action to enforce that.

  23. Liverpool Pathway = blatant killing.

    Once a patient is unconscious, how about depriving oxygen rather than water ? The sight of a doctor physically strangling the patient would show this for what it is…

    Don’t get me wrong – terminally ill people should be given as much love, care and painkillers as they need. Their eventual death should be as dignified as possible.

    Deliberately killing people is conveyor belt mentality….

  24. For the NHS, it’s a question of resource allocation. You’ve got £x,000 to spend. Do you a) cure 100 people who go on to lead full and productive lives? Or b) keep a comatose body alive for another few months, the agonising pain barely kept at bay by drugs, knowing there can be no recovery, and letting the 100 potentially healthy people stay sick or die? Or c) ending them quickly and humanely and risk going to prison for murder?

    People who complain about medics taking cost into account in life-or-death decisions are effectively demanding that medics should work for free. If you consider it moral that nurses should get paid for saving lives, then there is a price. The money isn’t really about money, though, it’s really a way of apportioning the time and labour of medics, who are in short supply. It would be nice if we could save everyone, but we can’t. Given a choice, who do you save?

  25. The LCP is neither murder nor euthanasia. For bloggers who normally pride themselves on research and accuracy when commenting on topics outside of their areas of expertise, Tim and Julia are wide of the mark.
    The LCP is designed to achieve some comfort and dignity in the the 48 hours of life. It is initiated in those who are dying- not those who may or may not die. It does not kill people- death was inevitable anyway. Consent is a very difficult issue in very poorly patients, but will be obtained were it can. Prior to the LCP, people would often die in hospital undergoing futile treatments, often causing discomfort unnecessarily. As a fairly gung-ho oncologist, working in a field (lymphoma) where we get most patients into long-term remission/cure, I find the LCP a great step forward and would want to die on it myself

  26. Hoorah for Adam Gibb’s post @31. In any case, the Liverpool Pathway is, firstly, a set of guidance notes subject to the judgement of those medical professionals attending at the time and is not a mandated procedure, and secondly it does not preclude hydration.

    Yes, it’s often possible to extend the lives of the dying, but often the costs are immense (and I’m not talking about money).

    These are very hard calls to make, and involve judgements and debate we are all keen to avoid.

    I applaud the LCP for addressing these issues and although not perfect they’re the best guidelines we have. Like Mr Gibb, I hope to die under the LCP myself.

  27. Previous two commenters: the post objects to killing people without their informed consent. Your choosing to consent is irrelevant.

    On the broader issue: if in fact it’s possible to predict with certainty that someone is about to die (and many medical professionals say it is not), then why not just off them quickly and painlessly? That’s what we do in abattoirs.

    In particular, why go through a 4-day charade of dehydration and starvation masked by an opiate, from which there is no possibility of recovery?

    And do you not find it strange that a profession charged with preserving life should be actively killing 130,000 people a year?

  28. “JuliaM:

    A) in an abortion, the patient is the pregnant woman. Doctors and nurses who participate in abortions – there is a right in the UK not to do so – take the view that a fetus is not a person.”

    Yes. Just like they take the view that the LCP isn’t euthanasia. Or murder.

    As I said, whatever helps them sleep at nights, but don’t expect ME to swallow that!

  29. “Consent is a very difficult issue in very poorly patients, but will be obtained were it can.”

    I do love that qualification; ‘where it can’.

    And….where it can’t? Hey, doc knows best! And there’s the costs to think of…

  30. Julia M- are you aware of any of the laws or practicalities around consent? How do you consent someone who is confused? Or semi-comatose? What if they deteriorate so quickly you lose the opportunity to consent when ‘compis mentis’? Sarcasm is the last resort of the scoundrel…

  31. JuliaM: your concerns about abortion aside, what is your point? Because the impression I have is that the people who actually dedicate themselves to terminal care are doing their best for the patients, and you are sitting on the sidelines making snide remarks.

  32. There’s a very, very simple solution to all this, which is to complete a “Living Will” or “Advance Decision” (standard templates are available free via the internet) and I would urge anyone who hasn’t already completed such a form to do so now, for their family’s sake if nothing else.

  33. @ Julia M: Consenting those who are semi-comatose or confused is not merely hard, but actually both impossible and illegal. As mentioned in my previous posts, a little research when commenting on issues outside of your field of expertise would go a long way. Instead you have merely revealed your ignorance. Death, dying and medical care at the end of life is one of medicine’s (and society’s)greatest challenges, and by no means do I pretend it is done well across the board. We all have our horror stories, but you’re barking up the wrong tree here. In addition , your sarcasm merely reflects your inability to engage in civilised debate.

  34. Adam & PaulB – nice to see the twin tropes of ‘it’s for our own good so shut up and let your betters decide’ and ‘you don’t know what you’re talking about and you’re mean with it!’ making an appearance.

  35. Adam Gibb wrote:
    “The LCP is designed to achieve some comfort and dignity in the the 48 hours of life.”

    A snippet from the nightmarish corporate drivel purporting to explain the LCP:
    http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/liverpool-care-pathway/updatedlcppdfs/What_is_the_LCP_-_Healthcare_Professionals_-_April_2010.pdf

    “The patient will be assessed regularly and a formal full MDT review must be undertaken every 3 days.”

    Every 3 days of the last 48 hours? So much for “research”.

    Note that in all that terrifying, inane wank (for healthcare professionals!), they don’t actually say what the core process is: the application of sedation and the withdrawal of hydration.

  36. to churm rincewind and hoorah for adam gibbs from your futile words you bothwork in the same hospital, are you both seeking promotion say on the tick box scam were you sentence a patient to death, churm rincewind you say the cost to extend live is immense and not talking about money you hit the nail on the head it saves the n h s money but kills patients on the back door euthanasia adam gibbs mentions people are complaining outside the area of expertise, are professor pullicino a consultant neurologist who says the l c p is equivalent to euthanasia, it is assisted death pathway rather than care pathway, and expertise dr. peter millard emeritus professor at the university of london. also dr peter hargreaves a palliative care consultant at st lukes cancer hospital in guldford surrey, warned about the dangers of back door euthanasia, he also says predicting death in a time frame of 4 to 5 days is not scientifficaly possible, and six top doctors spoke against it in a national newspaper,

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