Saturday, January 05, 2013

Care programme with 'a lethal character'?

The Liverpool Care Pathway is a programme which allows medication, food and water to be withheld from hospital patients, and patients to be sedated, during the last days and hours of life to prevent unnecessary distress during the dying process.

Newspapers claim that patients have been placed on the pathway who have not been dying, with the result that they would have died from use of the pathway. They also claim that thousands of patients have been placed on the pathway without the patients being informed or their families consulted.

Of the 450,000 who die in Britain each year, 130,000 now - almost a third - are said to have been on the pathway.

Dr Jacqueline Laing, senior lecturer in law at London Metropolitan University, says only a year after the Department of Health recommended the LCP as its end-of-life care strategy in 2008, 300 hospitals, 560 care homes and 130 hospices had introduced the programme.

One enterprising journalist, using provisions of the Freedom of Information Act, discovered that hospitals have been given financial rewards for placing patients on the LCP. NHS trusts have received payments totalling millions of pounds for reaching targets relating to use of the pathway. Some hospitals doubled the number of patients dying on the pathway in one year.

The Christian Medical Fellowship has called for financial incentives to be scrapped immediately and for patients to be treated solely according to their need.

Dr Laing, writing in the New Law Journal, says some fear the LCP has a homicidal character not acknowledged by its proponents. "When a patient is clearly in the last hours of life, it may well be that acts recommended by the strategy are entirely appropriate. The problem arises when they are not indicated, ie on the strength of misdiagnosis, or when the sedation-dehydration regime is implemented to satisfy managerial targets or countless other unjustifiable possibilities.

"Part of the difficulty is that, where a patient is diagnosed as terminal and imminently dying, the combination of morphine and dehydration is likely to undermine a patient's capacity. Persistent dehydration of even the fittest sedated patient will kill him. This was the problem with the Pathway from the very outset. . . 

"Recent revelations of financial incentives and staggering compliance in rolling out the managerial programme radically alter the debate. Diagnostic concerns in the context of arguably self-fulfilling sedation-dehydration regimes and overarching financial and political pressure to implement the Pathway suggest that the regime may have acquired a lethal power of its own. This lethal character is almost certainly one that exists independently of the best intentions of those who formulated or apply it. . . 

"Incentivised and managerialised death targets become problematic in the context of uncertain diagnosis, a steadily ageing population, spiralling healthcare costs, and the philosophical dehumanisation of the vulnerable pervasive in contemporary bioethics. The targets themselves constitute improper pressure on healthcare professionals' employment and livelihood. As such, they predictably invite and rationalise grave human rights abuse with tragic consequences for the defenceless."

Some critics ask what benefit the LCP or any other integrated pathway brings to patients which traditional pain relief and symptom control, pioneered by Dame Cicely Saunders, could not. They say there have been no controlled trials.

Results of an inquiry into the use of the Liverpool Care Pathway are eagerly awaited. What effect they will have in practice remains to be seen.