Peter Saunders

Is the NHS really killing 130,000 patients a year with the Liverpool Care Pathway?

Peter Saunders

The Daily Mail and Daily Telegraph recently ran a story claiming that the NHS ‘kills off a 130,000 elderly patients every year’ through use of a ‘death pathway’.

The story has been picked up relatively uncritically by many news outlets around the world, and particularly pro-life sites.

The claims are based on comments made by Professor Patrick Pullicino, who spoke at a Medical Ethics Alliance conference at the Royal Society of Medicine this week.

There are around 450,000 deaths in Britain each year of people who are in hospital or under NHS care. About 29% - 130,000 - are of patients who are on the Liverpool Care Pathway (LCP).

Professor Pullicino claimed that far too often elderly patients who could live longer are placed on the LCP and that has now become ‘assisted death pathway’ rather than a ‘care pathway’. He cited pressure on beds and difficulty with nursing confused or difficult to manage elderly patients as factors.

He also recounted how he had personally intervened to take a patient of the LCP who later went on to be successfully treated.

What do we make of all this? Are these national newspapers really revealing unprecedented levels of euthanasia in British hospitals or are these claims simply alarmist?

The Liverpool Care Pathway for the dying patient (LCP) is a treatment pathway used in the final days and hours of life which aims to help doctors and nurses provide effective end of life care.

It was initially developed between the Royal Liverpool Hospital and the City’s Marie Curie Hospice in the later 1990s and recommended to hospitals by the National Institute for Health and Clinical Excellence in 2004.

In 2006 a Health Department White Paper said it should be adopted across the country and it is now very widely used.

Before a patient can be placed on the pathway the multi professional team caring for them have to agree that all reversible causes for their condition have been considered and that they are in fact imminently dying.

The assessment then makes suggestions for palliative care options to consider and whether non- essential treatments and medications should be discontinued.

However it is by no means a ‘one way street’ and the patients on it are meant to be repeatedly assessed and taken off it if they show signs of improvement.

The programme provides suggestions for treatments to manage symptoms such as pain, agitation, respiratory tracts secretions, nausea and vomiting or shortness at breath that dying patients might experience.

After criticism by the Daily Telegraph in 2009 the LCP went through a further revision and version 12 was launched on the 8 December 2009 after over two years of consultation.

The new version was an improvement on previous ones and made absolutely clear that patients must be imminently dying (ie. within hours or days of death) before being placed on the pathway.

The 2009 Telegraph story was criticised by the Association of Palliative Medicine and the Care Not Killing Alliance as inaccurate. The Times welcomed it as an attempt to address patients’ wishes and warned about alarmist press coverage.

The Department of Health has responded to these latest allegations by saying that ‘the Liverpool Care Pathway is not euthanasia and we do not recognise these figures’ and adds that the pathway has had overwhelming support from clinicians both at home and abroad including the Royal College of Physicians.

Patients should be monitored at least every four hours and if they improve they are taken off the pathway and given whatever treatment is best suited to their new needs. An audit of the pathway’s use in 2009 showed that ‘where the LCP is used people are receiving high quality clinical care for the last hours and days of life’. This audit reviewed end of life care in 155 hospitals and examined the records of about 4,000 patients.

A 2012 audit looked at data from 178 hospitals (from 127 trusts) and examined 7058 patients records.

What we are seeing this week is a classic application of the ‘post hoc propter hoc’ fallacy, the mistaken notion that simply because one thing happens after another the first event was a cause of the second event.

It is certainly true that 130,000 British patients per year are dying whilst on the LCP. But it does not therefore follow from this that the LCP is the cause of their deaths.

If a patient is judged to be imminently dying and is placed on the LCP and dies within hours or days one can be virtually certain that the death was caused by the underlying condition.

However, on the other hand, if a patient is placed on the pathway and has hydration and nutrition removed whilst being sedated and dies, say ten-fifteen days later, then there must be a very real question about whether the withdrawal of hydration actually contributed to the death. But to put a patient on the LCP for this length of time is quite inappropriate.

I have no doubt that there are some patients who are not imminently dying who are being placed on the LCP inappropriately in Britain as Professor Pullicino has alleged.

However this is not the fault with the pathway itself but rather relates to its inappropriate use. Any tool is only useful if it is used with the proper indications.

The overwhelming majority of people on the LCP are experiencing much better care at the end of life than they would have had if it had not been used.

So what lessons can we draw from this story?

First, we need to be very wary of jumping to conclusions on the basis of alarmist headlines. Claims that huge numbers of people are being starved and dehydrated to death in Britain are not borne out by the facts.

Second, such claims run the risk of playing into the hands of the pro-euthanasia lobby who like to claim that doctors are killing thousands of British people with sedation, morphine and dehydration already and that legalising injection euthanasia will therefore change nothing.

Third, calling deaths on the LCP ‘euthanasia’ can also distract us from the very real threat of ongoing attempts to legalise assisted suicide and euthanasia. It can also undermine the public credibility of some of those who oppose euthanasia.

But finally, we also do need to be alert to doctors and other health care professionals, either through negligence, ignorance or perhaps even malicious intention, misusing a perfectly good care tool to speed the deaths of patients who are not imminently dying. That is why good audit and good supervision are so important. Any misuse of the LCP must be exposed and dealt with.

In good hands the LCP is a great clinical tool. But in the wrong hands, or used for the wrong patient, any tool can do more harm than good.

Reprinted with permission from Peter Saunders’ blog.

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Therapists to offer sex change drugs to nine-year-olds

Peter Saunders
Peter Saunders
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Children as young as nine are to be prescribed drugs which delay the onset of puberty as the first step towards a sex change operation (Mail on Sunday and Daily Telegraph).

Doctors at the Tavistock and Portman NHS Foundation Trust said a trial of the treatment on ‘gender dysphoria’ patients aged 12 to 14 had been successful and it could now be offered even earlier.

Monthly injections of the drugs, known as hypothalamic blockers, are used to slow the development of the children’s sexual organs by blocking the production of the hormones testosterone and oestrogen.

The rationale is that by delaying the onset of sexual maturation this gives more time for gender conflicted youngsters to decide whether they wish to embark on hormone treatment and surgery aimed at changing their gender. 

Most people will be shocked at this news but it is actually a logical consequence of accepting four prior ideological presuppositions – that gender is a social construct, that personal autonomy should trump other considerations, that emotional suffering should be avoided at all costs and that technology should be used to achieve these ends. 

There are obvious safety concerns - although the gender treatment is reversible, the long-term effects on brain development, bone growth and fertility have not yet been fully evaluated.

But safety considerations aside, using hormones to suppress puberty in transgender children is highly controversial, not least because of deep societal disagreements about the causes and nature of transsexuality and the effectiveness and appropriateness of transgender therapies per se.  This means that therapists remain strongly divided about the best way of handling the issue.

Transgender people are born with the anatomy and physiology of one sex but believe that they belong to the opposite sex.  Should therapy therefore be aimed at changing bodies (using hormones and surgery) to match a person’s beliefs or should it rather be aimed at helping people to adjust mentally to accepting the bodies they were born with? Even more fundamentally, is ‘gender dsyphoria’ a mental disorder or is it just a normal variant like eye or skin colour?

Up until recently ‘gender identity disorder’ was classified as a mental disorder (in the Psychiatric diagnostic inventory DSM-IV) but it has now been reclassified and renamed ‘gender dysphoria’ (in the DSM-V).  This change was strongly ideologically driven and many psychologists and psychiatrists dispute the reclassification. They still see ‘gender identity disorder’ as a kind of body dysphoria, whereby a person has an unshakeable false belief that they are one sex when in fact they are the other. It has been likened to anorexia nervosa, where the affected individual is convinced she is fat whilst being grossly underweight.

Those who supported the reclassification however, take the view that gender identity is biologically fixed and determined and that it is harmful to affected individuals to deny them sex change therapy or to 'force' them to live with the body they were born with. Some even hold to the strongly postmodern view that gender, regardless of what one’s genes or hormones suggest, is simply a social construct, even a matter of choice. If you wish to appreciate how passionately these views are held, then try expressing a traditional understanding on twitter using the hashtag #lgbt!  

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Is gender identity fixed as male or female or is it more of a spectrum or continuum? Can it change over time? How effective is therapy in changing the strength and orientation of one’s beliefs? How might suppression of puberty using hormonal treatment affect bone, brain and sexual development?

Research is still at an early stage with many of these questions and strong ideological convictions one way or the other mean that scientific objectivity about the real effects of sex change therapy may always be a matter of contention.  It is perhaps not surprising that both opinion and research in this whole area is often driven by powerful ideological vested interests.

Complicating this is the fact that gender identity may change in an individual over time, and that it may be very difficult to predict the outcome of for any particular person. Some children are much more appropriately described as ‘gender nonconforming’ or ‘gender-fluid’ rather than transgender. In many others gender identity may change with time.

Toronto specialist Ken Zucker, who opposes the use of sex change therapies, claims that only about 12% of boys and girls with gender dysphoria will still have persistent dysphoria as adults. This fact alone should lead even the most committed supporters of early intervention to err strongly on the side of caution.

The CMF File ‘Gender Identity Disorder’ goes into the issue in more detail and also looks at biblical principles which can be applied.

The Bible teaches that human beings are created in God's image and of two sexes – male and female (Genesis 1:27). Jesus drew on this when he commented, 'haven't you read, that at the beginning the Creator “made them male and female”, and said, “For this reason a man will leave his father and mother and be united to his wife, and the two will become one flesh” (Matthew 19:4-5).

The Old Testament command 'you shall not commit adultery' also indicates that sexual intercourse should only occur within the framework of marriage (Exodus 20:14). Sex outside the marriage bond is wrong, whether with someone of the same or opposite sex (Leviticus 18:22, 20:10).

The ideal pattern for existence was spoilt at the Fall when mankind rebelled against God's rules. One consequence of this is that moral values, sexual patterns and also biology (genes and hormones) have become distorted.

The good news at the centre of Christianity is that Jesus, through his death and resurrection, gives people new life and power to change. On top of this, there will be a time in the future when all rebellion against God's plans will come to an end and a perfect relationship with God can be fully restored. This brings the hope that transsexual people may find support as they seek to live in ways that are honest to the way God made them, and open to God's ideals.

It's worth noting that the Bible regards celibacy as a high calling. Jesus was fully human and male, but never married nor had sexual intercourse. He also taught that marriage is not for everyone (Matthew 19:12).  It is important to acknowledge this, as for some people, battling with gender conflict may be a life long process.

Reprinted with permission from PJ Saunders

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Why assisted suicide should not be legalised in Britain

Peter Saunders
Peter Saunders
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I have recently been published in a head to head with Sir Terence English in the Oxford Mail on whether assisted suicide should be legalised in Britain. My contribution to the debate is reproduced below. Perhaps not surprisingly I have said ‘no’.

Any change in the law to allow assisted suicide or euthanasia would inevitably place pressure on vulnerable people to end their lives for fear of being a financial, emotional or care burden upon others.
 
The ‘right to die’ would so easily become the ‘duty to die’. This would especially affect people who are disabled, elderly, sick or depressed and would be greatly accentuated at this time of economic recession with families and health budgets under pressure.
 
Elder abuse and neglect by families, carers and institutions are already real and dangerous and would be made worse.
 
Any so-called ‘safeguards’ against abuse, such as limiting it to certain categories of people, will not work.
 
This is because exactly the same arguments – autonomy and compassion – would apply to people outside the categories decided upon and so any law allowing it for some would immediately be challenged under equality legislation.
 
If for terminally ill people, why not for those who have chronic illnesses but are ‘suffering unbearably’?
 
If for adults why not for ‘Gillick competent’ children? If for the mentally competent why not for people with dementia who ‘would have wanted it’?
 
The news coming from other jurisdictions which have gone down this route, particularly Belgium and the Netherlands, shows a pattern of incremental extension and pushing of the boundaries – an increase in cases year on year, a widening of categories of people to be included and people being killed without their consent.
 
Belgium has recently legalised euthanasia for children and in the Netherlands babies with spina bifida and people with dementia are already put to death.
 
This is why British parliaments have rightly rejected the legalisation of assisted suicide in Britain three times in the last seven years and why the vast majority of UK doctors, almost all medical groups including the British Medication Association (BMA), Royal College of Physicians (RCP) and Royal College of General Practitioners (RCGP), and all major disabled people’s advocacy groups are also opposed.
 
Persistent requests for euthanasia are extremely rare if people are properly cared for, so our real priority must be to ensure that good care addressing people’s physical, psychological, social and spiritual needs is accessible to all.
 
This issue is understandably an emotive one but hard cases make bad law and even in a free democratic society there are limits to human freedom. Our present law with its blanket prohibition on all medical killing does not need changing.
 
The penalties it holds in reserve act as a strong deterrent to exploitation and abuse whilst giving discretion to prosecutors and judges to temper justice with mercy.
 
Reprinted with permission from PJ Saunders

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Royal College of Ob/Gyn bars pro-life doctors from receiving its degrees and diplomas

Peter Saunders
Peter Saunders
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Doctors and nurses who have a moral objection to prescribing ‘contraceptives’ which act by killing human embryos are to be barred from receiving diplomas in sexual and reproductive health even if they undertake the necessary training according to new guidelines.

Under new rules issued by the Faculty of Sexual and Reproductive Health (FSRH) earlier this year these doctors and nurses are also to be barred from membership of the faculty and from specialty training.

The FSRH is a faculty of the Royal College of Obstetricians and Gynaecologists established on the 26th March 1993 as the Faculty of Family Planning and Reproductive Health Care. In 2007 it changed its name to the Faculty of Sexual and Reproductive Healthcare.

Whilst many contraceptives act by preventing the union of sperm and egg, some, including most IUCDs (intrauterine contraceptive devices) and the morning-after pill EllaOne (ulipristal acetate), also act by preventing the implantation of an early embryo. In other words they are embryocidal or abortifacient, rather than truly contra-ceptive.

Many doctors, of all faiths and none, have a moral objection to destroying human life and wish therefore to avoid using drugs or methods which act after fertilisation.

In fact this position was once held by the British Medical Association (BMA) when it adopted the Declaration of Geneva in 1948. This states, ‘I will maintain the utmost respect for human life from the time of conception even against threat’.

But in 1983 the words ‘from the time of conception’ were amended to ‘from its beginning’ due to sensitivities about increasing medical involvement in abortion. The word 'beginning' was left undefined, giving doctors the opportunity to argue, contrary to the biological reality, that early human life was not actually human life at all.

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Now it seems that doctors who wish to abide by the original wording of the Declaration of Geneva are to be barred from practising in certain medical specialties. This is an extraordinary about face.

The Faculty may argue that they are not barring doctors and nurses from practising, but simply from obtaining certain qualifications. But as many job appointments will be conditional on applicants having these qualifications this is effectively also a bar on practice.

Interestingly doctors who have a moral objection to abortion are still able to complete the Faculty’s qualifications because the Abortion Act 1967 contains a conscience clause which protects them. But there is no law protecting those who object to destroying human embryos.

Many Christians believe that every human life, regardless of age, sex, race, degree of disability or any other biological characteristic, is worthy of the utmost respect, wonder, empathy and protection.

This is based on the idea, taught in the Bible, that human beings are made in the image of God. In a society which is becoming more hostile to Christian faith and values it is perhaps not surprising that we are seeing institutional discrimination of this kind.

Perhaps it is time for Christian doctors and nurses, and others who share their prolife views, to set up an alternative training programme.

Reprinted with permission from PJ Saunders

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