Friday, 22 June 2012

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

The Daily Mail and Daily Telegraph this week have run 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 (see here and here).

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 his week’s 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.

14 comments:

  1. 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.

    Indeed, it is easy to see how the press would like to make a scandal out of it even when there isn't one there.

    An interesting, informative and balanced post.

    ReplyDelete
  2. An excellent article. I saw the piece on the LCP on lifesite news and was shocked at the inaccuracy. Unfortunately I think more will read that than this.

    I'd be interested to know your view on ceasing high-flow oxygen. It is burdensome and unlikely to change the end result, but I don't think there's any doubt that reducing or removing oxygen therapy hastens death. This has never been something that sits well with me.

    ReplyDelete
  3. "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."

    If the operation of the LCP was audited to check how often the above happened, use of the LCP would probably protect patients from euthanasia rather than the reverse. The only question I would have is whether 10-15 days is too long. Does it really take that long to die of dehydration.

    ReplyDelete
    Replies
    1. If they begin in a normal state of hydration yes. But if they are already badly dehydrated or there is a high ambient temperature then they could die earlier than this. Tony Bland took about three weeks to die.

      Delete
  4. Do these Doctors have to have the consent of the relatives? An ex-colleague of mine told the Doctors that she didn't want her Mum's drip taken down, next time she went in it had gone. She was quite upset that her wishes had been ingnored.

    ReplyDelete
  5. A very balanced and thoughtful artice. Those of us here in the USA who admire the MORAL commitment that the NHS represents appreciate your attempt to set the record straight. It seems to me that the LCP is essentially what we in the USA call a "comfort measures only" treatment plan. It is a bit different from ours, but the basic idea is the same. Like any treatment plan, it is appropriate for some patients and not others. And, guess what? Doctors and Nurses make mistakes! But, would anyone's end of life experience be better if left to a machine?

    ReplyDelete
  6. Thank you for sharing such type of information.there are very help full information for every one.keep sharing this type of information.Negligence Liverpool

    ReplyDelete
  7. http://epetitions.direct.gov.uk/petitions/18401

    ReplyDelete
  8. Bunch of nazis, take them money rabbing doctors and throw then in jail. People pay their whole lives into the system an what do you get, you get murdered by the state!

    ReplyDelete
  9. As we speak, My Grandad is on an LCP program, his Medication and all Monitor support was removed, only leaving him with Sedation, and Diamorphine, I don't know if I like the fact that he is not in-taking any food or drink, as I believe a good meal and regular fluid must have some goodness, I like the fact that he is peacfull and he seems comfy!. But I read a statement on this topic, stating that if any improvement is seen, they can withdraw a patient off LCP, yet not one doctor or nurse checked anything in relation to medical. It was just a case pretty much, with in the 14hrs I have sat at the bed side, of them asking if we would like drink's etc. I left with my Grandad, still breating and he seemed to just look as though he was sleeping, yet now I have a massive selection of thoughts running through my mind, which I know a Doctor/Nurse would not answer. I think I would feel a lot better if he wasn't sedated, and was just on the Diamorphine, meaning he felt no pain, yet was able to Speak, Eat & Drink, I don't know if any one can offer me any answers, but my emotions at the moment are just so hear there and every where, if any one is wondering if they asked to place him on LCP. The answer to that is yes! But I don't feel personally that my family has had time to let it sink in, to what is going on, I don't know if its good or bad, I really wish I could hear his view, or read his mind, but I suppose that is just wishfull thinking :-(

    ReplyDelete
  10. this liverpool care pathway or was it care, everyone who have been placed on it and doctors have made thousands should be compensated for the loss of a loved one or relatives it has been proven wrong to use thats why it has been scrapped, especially the bribery to pay money to put them on it until dead its a disgrace and very sad life taken early for cash.

    ReplyDelete
  11. this inhumane treatment the Liverpool care pathway has been implemented for much too long, professor Patrick pullicino,s statement to the media, and m p Fiona bruce made a big difference to the stopping of the lcp and professor glasier who his a specialist in cancer care, hitler got away with his starvation madness for quite a while but thousands were murdered before there time like the l c p has done its disgusting and relatives should sue, sue and sue, to help prevent it being done again.and again.

    ReplyDelete
  12. looking at the way the l c p was used to save money and make money, euthanasia should never be legalised look what will happen in the wrong hands patients comotosed with no say will be murdered once again without permission, and cost cutting in mind even though this l c p has been scrapped they still need to be watched its got into there blood to do unlawfull things to make it an easy life for them in other words the easy way out is death..

    ReplyDelete
  13. If the operation of the LCP was audited to check how often the above happened, use of the LCP would probably protect patients from euthanasia rather than the reverse. The only question I would have is whether 10-15 days is too long. Does it really take that long to die of dehydration.

    ReplyDelete