Thursday, September 3, 2009
A letter from a group of concerned doctors, including Dr. Peter Hargraeevs, a London-based palliative medicine physician, to the British Telegraph newspaper is raising concerns over the UK's National Health Service (NHS) implementation of a protocol called the Liverpool Care Pathway. The letter asserts:
"If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death. As a result, a nationwide wave of discontent is building up, as family and friends witness the denial of fluids and food to patients. Syringe drivers are being used to give continuous terminal sedation, without regard to the fact that the diagnosis could be wrong. It is disturbing that in the year 2007-2008, 16.5 per cent of deaths came about after terminal sedation. Experienced doctors know that sometimes, when all but essential drugs are stopped, “dying” patients get better."The news article to go along with the letter to the editor has some other statements that are potentially inflammatory as well which I won't go into too much detail here but may discuss in the comments.
For some background, the Liverpool Care Pathway (LCP) is an order set that covers many key areas of caring for dying patients. It was created by Royal Liverpool Hospital and Marie Curie Hospice and is now under development and guidance with the Marie Curie Palliative Care Institute.
(Picture from Drudge Report Website 9/3/9)
The group created the pathway to create a standard set of guidelines to "support ward teams to manage this episode of care in the generic area and we could impact on the care of patients whom we would never meet." The LCP has been recognized with awards and has collaborated and received the support of many UK insittuitions: National Council for Palliative Care, the National Kidney Foundation, the Royal College of Physicians, the Royal Society of Medicine and the Care Quality Commission.
The creators of the LCP realized that this was not a panacea for quality care of the dying. They give room for clinicians to make deviations from the LCP, and have made statements that the LCP is "only as good as the people using it" and in the LCP handout to health care professionals they note the need for an importance of culture change of medicine and death, and away from a disease oriented and more towards a person oriented model. The section is title "Winning Hearts and Minds."
So what is in the LCP? You can look at the four different (pdf) versions based on location of care: Hospital, Community/Home, (Inpatient) Hospice, and (Nursing) Care Home. The criteria for using the form include: Excluding possible reversible conditions and at least two of the following:
- The patient is bedbound
- Only taking sips of water
- No longer able to take tablets
I think we have come a long way in palliative care in placing more emphasis on understanding what the dying process looks like, how to manage symptoms aggressively while balancing the need for meaningful communication to and from the patient in the last hours and days of life. But when some basic palliative care principles are being misconstrued as systematic hastening of death, I am afraid we will go back to the Dark Ages of Medicalized Dying.