Tighten controls on UK’s end-of-life protocol over abuse concerns, says group of 20 medical bodies
LONDON, October 10, 2012 (LifeSiteNews.com) – A group of 20 medical bodies has said that the UK Department of Health needs to tighten controls on the controversial Liverpool Care Pathway, a medical protocol that pro-life campaigners have said is often used as a method of passive euthanasia.
After a consultant neurologist said in June that the LCP is being used to “clear” elderly patients out of scarce hospital beds, a ‘consensus statement’ by 20 UK medical bodies said that from now on, two doctors, one of whom is to be the most senior on staff, must sign off on the use of the protocol. The statement also said that the protocol does not require the removal of food and/or hydration from every patient placed on it.
The LCP was developed by a group of British bioethicists in the 1990s, and under the current rules it allows a single doctor to decide when a patient is in “the final days or hours of life” and to remove “medical treatment,” including food and hydration, while the patient is heavily sedated.
The statement comes from an array of interested groups, including the Royal College of General Practitioners, the Royal College of Physicians, the National Council for Palliative Care, pressure groups including Age UK and the Alzheimer’s Society, and the Royal College of Nursing.
“It is not always easy to tell whether someone is very close to death,” says the statement. “[A] decision to consider using the pathway should always be made by the most senior doctor available, with help from all the other staff involved in a person’s care. It should be countersigned as soon as possible by the doctor responsible for the person’s care.”
“The pathway,” the statement said, “does not preclude the use of clinically assisted nutrition or hydration – it prompts clinicians to consider whether it is needed and is in the person’s best interest.” The Pathway, they said, is “not in any way about ending life, but rather about supporting the delivery of excellent end-of-life care”.
Dr. Patrick Pullicino told a meeting of the Royal Society of Medicine in London that as many as 130,000 people had died under the LCP and that there is often a “lack of clear evidence” that a patient is dying when he is put on it. Far from being a last resort in the last possible extreme of terminal illness, the Pathway is often invoked as an “assisted death pathway rather than a care pathway,” he said.
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Steve Doughty of the Daily Mail quoted him saying that “pressure on beds and difficulty with nursing confused or difficult-to-manage elderly patients” are frequently-used criteria. He said that in one case in his own practice, a 71-year-old patient was admitted to hospital suffering from pneumonia and epilepsy, was put on the LCP, without his family’s consent, by a doctor on a weekend shift. Pullicino, Professor of Clinical Neurosciences at the University of Kent, said that he took the patient off the Pathway and when treatment was resumed the patient recovered fully and lived more than a year.
“Very likely many elderly patients who could live substantially longer are being killed by the LCP,” he said. “Patients are frequently put on the pathway without a proper analysis of their condition.
“Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically.”
Dr. Peter Saunders of the Care Not Killing Alliance, which supports the LCP in theory, warned that Pullicino’s statements could lead to misunderstandings. He said that an audit of 4000 LCP patients’ records in 2009 found that they are “receiving high quality clinical care for the last hours and days of life”.
Saunders wrote, “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.”
In cases where the patient is placed on the Pathway and dies ten to fifteen days later, Saunders added, “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.”
The LCP requires that patients only be judged eligible if they are within hours, or at most days, of death. They must be monitored and checked every four hours and if any improvement is seen, the protocol requires that treatment be resumed.
Other voices have been raised more strongly in warning against the LCP. In a July letter to the Daily Telegraph, seven doctors, including the heads of the Medical Ethics Alliance and the group First, Do No Harm that champions traditional medical ethics, warned that the LCP can be misused through several means.
“Other considerations” than those purely medical issues laid out in the Pathway protocol could easily be influencing doctors’ decisions, “not excluding the availability of hospital resources,” they warned.
“The onus of proof that the pathway is safe and effective, or even required, is upon its authors, who should furnish their evidence.”
They said, “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.”
The physicians added that “informed consent is another major consideration” and that it is “not surprising” that patients are including a written refusal of the Pathway in legally binding “advance directives,” or “carrying cards refusing this form of treatment, as a measure of self-protection”.
Saunders said that his group regards the LCP itself to be “a great clinical tool” but warned, “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.”
“Any misuse of the LCP must be exposed and dealt with,” he said.
The slide towards the routine use of withdrawal of food and hydration has been going on a long time. It started with the 1993 case of Tony Bland, a man who had suffered brain injuries and was in a coma. The hospital, with the support of his family, applied successfully to the courts to remove his hydration, an act that was uniformly described in the press as “allowing him to die with dignity.”
A physician with the Royal Hospital for Neurodisability later wrote that this decision was a major turning point in the history of medicine, in that “instead of considering the futility of the treatment, the burden of the treatment ... the decision for the first time considered the worthwhileness of the patient, and the burdensomeness of the patient himself.”
The Mental Capacity Act 2005 codified the definition of food and hydration as “medical treatment” that could be removed if a doctor decided a patient’s future expectations did not warrant him being kept alive. Since the Bland case, doctors who have petitioned the courts to remove food and hydration have never been refused.
A 2004 letter from the Bill Policy Officer in the Mental Capacity Bill legislative Division, to the Association of Lawyers for the Defence of the Unborn said the government has no intention of overturning Bland. Since the Bland decision, courts have sanctioned “around 36 cases” of deliberate killing by withdrawing assisted food and fluids, “and the Government does not disagree with it,” the letter said.
This legal history is the atmosphere in which the Liverpool Care Pathway was developed and in which it was decided that patients who are judged to be nearing the end of their lives could be refused food and hydration. In a 2008 article in the British Medical Journal, Dr. Adrian Treloar a geriatrician, said that the eligibility criteria “do not ensure that only people who are about to die are allowed on to the pathway”.
“For instance,” he warned, “patients with dementia, in whom dying can take years, and those who are bed-bound and unable to swallow may be eligible.”