On that Liverpool Care Pathway

Worth reading the whole thing actually but:

One of Britain\’s leading neurologists has revealed his fears about the use of the Liverpool Care Pathway as he disclosed how one of his patients survived for 14 months after being taken off it.

Hmmm.

The consultant neurologist said the case demonstrates that doctors should not be allowed to forecast death, which became a \”self-fulfilling prophecy\” once treatment and sustenance were withdrawn.

Prof Pullicino said: \”There is no objective criteria to say whether a person is dying or not – there is no scientific way to know, and that means the system is open to terrific abuse.

\”If you stop treating someone for their condition they are unlikely to improve. If, on top of that, you sedate them heavily, you are unlikely to see any improvement even if it does occur. That is why putting patients on the pathway becomes a self-fulfilling prophecy.\”

The consultant said he believed that doctors taking such decisions were often making a judgement about the patient\’s quality of life, not about whether they were close to death.

And:

Prof Sam Ahmedzai, a leading palliative care doctor, said he was worried that \”inhumane\” decisions were being taken by doctors who did not know the patient being discussed, and were in a poor position to make judgements about their prognosis.

He said: \”What often happens though is that the decision is taken out of hours, at weekends, basically by strangers who have never seen that patient before and never will again.\”

It was \”unforgiveable,\” said Prof Ahmedzai, professor of palliative care at the University of Sheffield, for life and death decisions to be made in such a way.

There\’s a difficult line here. Obviously.

Someone whose going to be dead tomorrow from their lung cancer probably doesn\’t need the crash team to break their ribs as they restart their heart after it stops. But that\’s rather different from stopping the antibiotics and water going into someone with pneumonia who could, as above, survive another 14 months.

And let me be honest about my worry here: bureaucracies really don\’t deal well with such fine lines.

29 thoughts on “On that Liverpool Care Pathway”

  1. PaulB will be along in a moment to point out that the only ‘decent’ thing to do is to support the NHS. He once had a mate who walked off some scaffolding, you know.

  2. Incompetence is one thing, but do people really want bureaucracies deciding who lives and who dies?

    There are plenty of countries around the world whose histories will tell you that when the State controls such things, food, healthcare, etc, they abuse it and use it to control you.

  3. @Interested: yes, PaulB will be along to tell us its all OK, as the rules for the LCP are all written down somewhere, and the wonderful people that run the NHS would never exceed their authority, or make a wrong decision.

    And then lost_nurse will chime in to say she’s had a very hard day in A&E patching up drunks, so all of you shut up about the NHS, its all wonderful, and far better than those horrible Americans, and just let them get on with clearing bed space by putting old folk who haven’t got any family to kick up a fuss about it on the LCP (oops sorry, I mean easing passage of the terminally ill of course!).

  4. We had this with my father-in-law a couple of years back. He got pneumonia and some doctor decided he shouldn’t be resuscitated because he didn’t have much of a lifestyle. Yes, he spent a lot of time just sitting at home (he was rather stubborn and would refuse outings if he didn’t fancy them) but he was surrounded by a very large family and not a day went by without a visit from children or grandchildren.

    When MrsBud (PBUH) found out about the no resuscitation she phoned the doctor from Australia (that being where we live). Initially he refused to speak to her, claiming members of the family had already been consulted, by which he meant a bro-in-law with mental health problems and my barely conscious father-in-law who is of that generation that never questions doctors. Being a health care professional, MrsBud made it clear that he could talk to her or she’d take the matter above his head, she then told him to remove the no resuscitation and make a full record of their conversation in my father-in-law’s notes.

    My father-in-law lived a little over two more years, dying of an entirely unrelated heart attack. Throughout his extra two years he was visited by those he loved every day and got to see Aussie grandchildren he hadn’t seen in a while.

  5. I-ll spare you the unpleasant story of my father-s demise.

    But they started they -do not resuscitate- routine within a day or two of him going into hospital–because my mother couldn’t cope.

  6. Apostrophes only seem to break within blockquotes.

    On the LCP, my mum was on it. We didn’t mind that as such, since she was certianly in the final stretch after a massive brain haemorrhage. What did appall us was (a) she really should have been morphined to death instead of lying there gasping for a week and (b)nobody bothered to even tell us until a nurse mentioned “LCP” and my sister said, “what’s that then?”.

    In general, I think the whole thing’s a fucking disgrace. Frankly it was much better when a tweedy doctor would happen to quietly mention to the primary carer that an overdose of *this* much would probably finish it all, so don’t accidentally do that, now.

  7. The Liverpool Care Pathway is indeed a thoroughly good thing, as anyone who takes the trouble to read what it says will realise.

    The case Prof Pullicino describes is not a failure of the LCP, but a failure to follow the LCP, both in the way the decision was made and in the failure to inform the family of it.

    There are two ways to do things. One is to keep everyone alive for as long as possible, including, as Tim fears, breaking the ribs of dying cancer patients. The other is to give doctors discretion on how much striving is appropriate. If you follow the latter course it’s a good idea to have guidelines on how to exercise that discretion. That’s the LCP.

    I’m reasonably sure that Prof Pullicino has the authority to insist that weekend and out-of-hours staff must not put his patients on the LCP without consulting him.

  8. To add to what PaulB has correctly said, if the LCP is being followed, no conscious patient would be placed on it without their own consent.

    In broader terms, either you trust doctors (in general) or you don’t. If you don’t, then you surely don’t think they need the LCP to kill patients as and when desired. If you do, then you must admit that whilst the LCP isn’t perfect, it at most needs some tweaks; it’s attempting to do the right thing, and mostly succeeding – the problems are that it’s not always correctly used.

  9. What utter bollocks, PaulB. Doctors should be given no discretion whatsoever, they are providing a paid for service. They may offer their professional opinion, which people may or may not choose to abide by, but the decision as to the extent to which the service provider should go to preserve life lies solely with the client, i.e. the patient or their family.

    @Dave

    No, I don’t trust doctors, which is why I don’t carry an organ donor card. I trust those who love me to make an informed decision.

  10. Docbud>

    “the decision as to the extent to which the service provider should go to preserve life lies solely with the client, i.e. the patient or their family.”

    Which is exactly what the LCP says. Personally, I disagree with that. Family are often the last people who should be making such a hard decision – they commonly lack both the training, and the emotional detachment, to make a good judgement of what is best for their loved ones.

    “I don

  11. Oh for god’s sake. Continued…

    t trust doctors”

    To what extent? I just don’t see how that works, because there’s no profession with more opportunity to kill people if they want. Every time a doctor gives an injection, or some pills, they could be poisoning you. Given how few patients drop dead of such things – Shipman was a very rare exception – the conclusion can only be that the overwhelming majority of doctors are doing their best to help people, and at worst simple disagree (with you and each other) on what the best way to help people is.

  12. The last thing you need in matters of life and death is “emotional detachment”.

    This is the managerialist nightmare that we as a society, having dodged fascism and communism, have stumbled into.

    I think a lot more people need to get their fucking heads around David Hume’s insight from centuries ago that ethics and morals derive from sentiment, not reason. You use your reason to achieve your desires, which are themselves derived from sentiment.

    The desire to stay alive is not subject to rational criticism. Neither can an algorithm represent it. It just doesn’t work that way, at a fundamental, basic, “laws of nature” kind of a way. How hard is this?

  13. DocBud: not bollocks at all. There is no right in UK law for a patient to insist on any particular treatment.

    What the doctor is supposed to do is explain to the patient any treatment options she considers beneficial, giving the patient the medical information he needs to make a choice. If the patient lacks mental capacity, and there is no Lasting Power of Attorney, the doctor is supposed to make her own determination of what the patient would have wanted, consulting friend and relatives of the patient to help her decide.

  14. I entirely agree with Hume. We derive ethics and morals from our emotions to guide us at times of great emotional stress. This then allows us to detach ourselves from our emotions without losing sight of what they tell us.

    Emotional detachment may be a modern term, but it seems to be precisely what Hume was talking about.

  15. Dave, what I should have said is that I don’t trust the judgement of doctors in matters of life and death. My experience also suggests that they are not always reliable at recommending the best course of action. I do however trust my doctor to not want to kill me.

  16. Gah. Cointinued…

    “t trust the judgement of doctors in matters of life and death.”

    That seems more reasonable, but what does it actually mean? What don`t you trust them to do? Follow clearly laid-out rules? Or formulate the rules, with our input?

    “My experience also suggests that they are not always reliable at recommending the best course of action.”

    Common sense tells you that. “Not always reliable” means fallible. Does anyone suggest doctors are infallible?

  17. What it means, Dave, is that when it comes down to deciding if now is the right time for me to be buried 6 ft down in a box, I don’t want someone who doesn’t know me from Adam deciding that yes, now is the right time because my lifestyle seems pretty crap to him or her. It is a rather obvious point that death is for ever and when it looms large, most of us, if still quick of mind, would rather have a little more time before shuffling off this mortal coil (perhaps to read Hamlet one last time).

    Yes, doctors are fallible (they’re not engineers after all), all the more reason not to unquestioningly accept their judgement on when is a good time to snuff it.

  18. WTF is going on? I even changed the apostrophe to a back-tick.

    “… know me from Adam deciding that yes, now is the right time because my lifestyle seems pretty crap to him or her.”

    Given that would only happen if you were no longer compos mentis, why should you care?

  19. Dave, see my post above about my father-in-law. He wasn’t too compos mentis when he had pneaumonia but certainly was for most of the little over two years he lived once he recovered.

    My father had double pneaumonia earlier the same year. He had to be resuscitated (someone else on the ward told us the crash team worked long and hard on him in the middle of the night). He is still going strong and enjoying his ‘extra time’. Very often, it seems, it comes down to the attitude of the doctors and hospital, West Yorkshire for my father-in-law, Surrey for my father.

  20. the doctors know full well it his a wrong way to treat an ill patient it should be abolished now not six months later when thousands more have bee murdered there is no other name for it ask all the whistle blowers, they know they work in the hospitals stop it now david cameron you should be fully ashamed of yourself to allow this back door euthanasia to continue.

  21. well spoken ex nurse you are to be admired for trying to help save innocent lives you live once on this planet and once only so every days a bonus, and the bonus they give the doctors and nurses for getting a bonus to put patients on it should be abolished instantly it was found out in the freedom of information act.

  22. after reading and geting fuck stress out i cant belive mariecurrie put my dad on lpp with out my consent my neice phoned me i had left to get change of clothes and some nurse came in when her granda was geting his hair cut by her and told her see did not have a clue my da had mesothelom asbestos cancer she phoned me and i eas thete infifeteen mins my head was ovr the pl but they asked me to sign as i ead next to kin i stayed way mada they said it eas das attmitece then nurse asured me it was the best thing for dad i have just read mariecurrie reveiws on LCP and the nurse that visited us in the house see new my da wanted to stay in the house and the two nurses that that me lies i will make sure they never speak to any family in my position i will have to live with not honor my das wishes to be in his house when he past i dont think i can livewith that bad enough to lose him but i could have had him home instead they cut his short live even shorter shame on them know what happens to me at lest i will be with ma dax

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