This is an important read about the problems with the Liverpool Care Pathway and its use in the UK. It is also worth reading this from the point of view of euthanasia because it gives an insight into what happens in practice when a protocol with very clear intentions falls into disuse and misuse over time. Alex Schadenberg writes:
On July 14, columnist Melanie Phillips, wrote a profound article concerning the demise of the Liverpool Care Pathway in the UK.
Her article was published in the Daily Mail under the title: Hope at last on the pathway to death - but the NHS still has a hole where its heart should be.
Phillips begins her article by explaining what the Liverpool Care Pathway (LCP) was:
The LCP was written as a treatment programme for doctors and nurses when looking after people who are dying.
Such a programme was deemed necessary because of the all-too-common instances of neglect or inappropriate treatment which dying people were being forced to suffer.
However, the scheme became mired in bitter controversy after relatives and patients claimed that the LCP was being used to accelerate death, or even to kill patients who were not dying at all by starving and dehydrating them until they did, in fact, die.
Worse still were claims of financial incentives for hospital trusts to bump up the LCP numbers.
Despite vehement protests by the medical and nursing professions that these claims were unfounded, the Government set up an inquiry into the practice.
It is expected to report today that there were numerous instances of abuse under the LCP, and to say that it should be phased out, a recommendation with which the Care and Support Minister, Norman Lamb, will agree.
When I myself wrote about these abuses, I was all but swamped by the reaction.
People wrote in droves with harrowing tales of watching in horror as their elderly relatives were deprived of food, water and medicines when they were not dying at all, but merely seriously ill or feeble in mind.
At the same time, however, outraged doctors and nurses deluged me with accusations that I wanted to inflict cruel and wholly inappropriate treatment upon dying patients.
Indeed, as soon as the reports first surfaced over the weekend that the Government was intending to end the LCP — even before I had seen these stories — I was already receiving tweets accusing me of having brought about an end to the humane care of the dying.
Such ill-judged anger among health professionals and others about criticism of the LCP surely derives from precisely the fundamental confusion or callousness that led to the abuses.
The government announces significant changes:
Mr Lamb struck an ominous note, for example, when he said the LCP’s replacement would not be called a ‘pathway’ — which suggested that these practices might continue under a different name.
He says that end-of-life care will now be tailored for individual patients. But this fails to identify the very confusion at the core of this problem. This arises over the issue of medical staff being able to identify correctly when someone’s life is about to end. For the advice at the core of the LCP is, in fact, nothing other than basic good medical practice in care for the dying.
When someone really is dying, it may indeed be inappropriate, intrusive or even cruel to continue with treatment, feed them through tubes or inflict upon them similar pointless procedures.
They should instead be kept comfortable and free of pain, offered nourishment if they show they want it, or merely have their mouths moistened.
The inevitable process should be allowed to take its course — but only if it is indeed the irreversible closing down of all bodily functions which dying entails.
The Liverpool Care Pathway abuses occurred, however, largely because it was applied to patients who were not at the end of their lives, but who were starved or dehydrated to death.
Health care professionals either did not understand that someone who was extremely ill or mentally incapable was not actually dying — or, worse, they thought such a life was not worth extending and so terminated it.
Such staff often find it remarkably difficult to tell when someone really is dying. I recall that when my own father was a few hours from death — a call made correctly by the nurse who was caring for him — the GP who arrived to treat his discomfort airily asserted that he might live for several more weeks, and was duly abashed when he had to return later that evening to pronounce my father dead.
But this problem has been exacerbated by a deeply troubling modern development. This is the progressive inability to distinguish between someone who really is dying and someone who it is thought should be dying because they are deemed to have such a poor quality of life.
The abuses that have occurred with the Liverpool Pathway are the same abuses that are occurring in Canada and nearly every "first-world" nation. The article continues:
This appalling leap of logic was cemented into English law by the watershed case of Tony Bland, the Hillsborough disaster victim who was left in a persistent vegetative state.
In 1993, a court ruled that his food and hydration tubes could be removed. That fateful ruling effectively permitted intentionally ending the life of someone who was not dying.
In other words — although the courts have never acknowledged this fact — this legitimised killing a patient in certain circumstances.
The Rubicon having thus been crossed, some health-care staff proceeded to withdraw food and hydration from numerous elderly or incapable patients on the grounds that their quality of life was inadequate.
Indeed, so poor did they judge this quality of life to be that they claimed such patients were dying. Which, of course, they were not — until these doctors and nurses made it so.
At the core of all this lies the crumbling of the notion that there is an absolute value to human life. ...
And it is the erosion of this innate respect for life which lies in turn behind the steady brutalisation of care for the elderly and incapable in our hospitals.
We saw this, to our horror, in the Mid-Staffordshire hospital trust scandal, where the neglect of patients plumbed such depths that some of them were forced to drink water from flower vases to quench their desperate thirst.
And now another report to be published this week will apparently deliver the bleak, if all-too-predictable, revelation that shockingly inadequate standards of care in some 14 hospital trusts have caused the needless deaths of no fewer than 13,000 patients since 2005.
In Canada our healthcare system is also dehydrating people to death, who are not otherwise dying. Phillips then comments on the state of the National Health Service (NHS) in the UK:
Harsh as this may sound, it is surely hard not to conclude that — whether through the LCP abuses or shocking standards of care — one way or another the NHS has turned into something akin to a national death service for those who are too vulnerable to resist.
This obscene brutalisation of attitudes cannot be addressed by tinkering with procedures, by yet more Whitehall directives, nor even by the firing of culpable staff (not that that last outcome ever seems to happen).
We are simply facing nothing less than a moral breakdown: a fundamental collapse of decency, compassion and simple kindness.
These have been replaced in too many cases by hatchet-faced self-interest, an arrogant and unchecked abuse of professional power and a brutal utilitarianism which has substituted a tendentious judgment of usefulness for innate respect for human life.
That this has occurred in the NHS, Britain’s supposed temple of caring, does not merely explode that particular claim for the humbug that it is. It is also a judgement upon a narcissistic society which, in sentimentalising the NHS in this way in order to admire its own compassion and altruism, has, in fact, developed a cruel and callous hole where its own heart should be.
Everyone needs to read this article. The problems with the Liverpool Pathway are the same problems that are occurring across the "western-world."
In Canada we are experiencing a crisis of care within our medical system as we continue to build a more centralized, controlled, bureaucratic, financially bankrupt, morally negative system. We have stopped caring about individuals and we have turned "best practices" into a one-size fits all system.
Every nation needs adopt systems of patient centred care.
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