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End-of-life care pathway 'used to cut costs'

Hospitals may be withholding food and drink from older patients so they die quicker to cut costs and save on bad spaces, leading doctors have warned.

Thousands of terminally ill people are placed on a “care pathway” every year to hasten the ends of their lives.

But in a letter to the Daily Telegraph, six doctors who specialise in older people’s care said hospitals across the UK could be using the practice to ease the pressure on resources.

The Liverpool Care Pathway, which withholds fluids and drugs in a patient’s final days and is used with 29 per cent of hospital patients at the end of their lives, is backed by the Department of Health.

But the six experts told the Daily Telegraph that among older people, natural death was more often free of pain and distress.

The group warned that not all doctors were acquiring the correct consent from patients and are failing to ask about what they wanted while they were still able to decide.

The doctors say that this has led to an increase in patients carrying a card stating that they do not want this “pathway” treatment in the last days of their lives.

One of the letter’s signatories, Gillian Craig, a retired geriatrician and former vice-chairman of the Medical Ethics Alliance, told the newspaper: “If you are cynical about it, as I am, you can see it as a cost-cutting measure, if you don’t want your beds to be filled with old people.”

A DH spokesman said: “People coming to the end of their lives should have a right to high quality, compassionate and dignified care.

“The Liverpool Care Pathway (LCP) is not about saving money. It is an established and respected tool that is recommended by NICE (National Institute for Health and Clinical Excellence) and has overwhelming support from clinicians at home and abroad.

“The decision to use the pathway should involve patients and family members, and a patient’s condition should be closely monitored.

“If, as sometimes happens, a patient improves, they are taken off the LCP and given whatever treatments best suit their new needs.

“To ensure the LCP is used properly, it is important that staff receive the appropriate training and support.”

Readers' comments (30)

  • Tiger Girl

    'The group warned that not all doctors were acquiring the correct consent from patients and are failing to ask about what they wanted while they were still able to decide.

    A DH spokesman said: “People coming to the end of their lives should have a right to high quality, compassionate and dignified care.

    The decision to use the pathway should involve patients and family members, and a patient’s condition should be closely montiored.

    To ensure the LCP is used properly, it is important that staff receive the appropriate training and support.”

    This needs to be used properly, not improperly. Like everything else.

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  • 'hospitals MAY be witholding ............

    what a dreadful thing to say, where is the evidence that this is happening, what a terrible accusation to make.

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  • I don't for one minute think doctors think about the cost. I agree it is a dreadful thing to say. The LCP is about comfort if a patient can still eat and drink that is fine if not IV fluids can be given following a discusssion with their family.

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  • Adam Roxby

    This has created quite a storm on twitter which I have been following. I don't want to give anything away, but this might be featured in the next episode of the Student Nursing Times Podcast so watch this space.

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  • Oops I've offered patients on the LCP water before and I think I've seen family members do it too... (luckily most of the patients refuse it, are unconscious or can't swallow anyway). I was told to do whatever to make them comfortable. Better read the paperwork more carefully next time!

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  • The letter the doctors wrote suggests sub-cut fluids to ease thirst - how does that work? When they say doctors 'withold drugs' it's not quite like that is it.

    They also suggest that in the elderly a natural death was free of pain and distress - really? how do they know? might it have something to do with the fact that a lot of older people are stoic, or perhaps they can't express their distress or pain, particularly at the end when they may be semi-conscious.

    The card that patients are supposed to carry saying they don't want to go on the LCP - has anyone here ever seen one? If so can you copy and paste it please.

    Very unkind and misleading article which does nothing to help anyone.

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  • It seems there is a misconception in the media and among the public of the LCP.

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  • Sin to Heal Me ?

    Anonymous | 10-Jul-2012 10:09 am
    Anonymous | 10-Jul-2012 10:13 am

    Yes, quite !

    I read this story in the paper - The Medical Ethics Alliance is a Christian group, with a perspective/agenda it seems.

    There is confusion, in what is being reported of their position - i.v. fluid is quite different from drinking a glass of water, etc - and I am not exactly certain what they did write in their paper.

    However, some people perceive the LCP and similar as 'killing the patient' - it all looks very dubious, legally and ethically, if clinicians start to decide what a patient wants, without getting that instruction from the patient.

    And Adam, will you also place your feedback highlights in this set of postings, if possible - your comments are always interesting.

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  • from Anonymous | 10-Jul-2012 10:13 am

    Hi, Sin to Heal Me ? | 10-Jul-2012 10:59 am

    The public obviously needs to be somehow far better informed about end of life care, the LCP and the boundaries between personal choice and clinical decision making. I too have followed it in the national press and reading some of all the hundreds of comments I have discovered that so many different issues have been introduced into all the arguments that it results in total confusion and many do not have a clear understanding of what care their loved ones and others receive, the quality of that care, the skills and clinical judgement involved and limitations of nursing and medicine.

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  • There is a section of the LCP which states that patients are assisted to take oral fluids for as long as possible and artificial hydration is to be considered so I don't understand what is going on here.

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  • Anonymous | 10-Jul-2012 1:01 pm

    well somehow a wrong message has been sent out to the public and it is being used as another weapon to beat hospitals and their staff with.

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  • I personally believe the LCP is an extremely useful tool to use. It ensures high quality care is delivered to the patient and that all services within the multi disciplinary group have access to what is going on rather than everyone keeping separate notes etc...
    My only perception is that the LCP is for the benefit of the Patient and all who care for them.

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  • Tony Probee | 10-Jul-2012 2:30 pm

    the question is, how foolproof is it. it seems that tools such as guidelines, protocols, pathways, etc. are only as good as those using them. If there is sound evidence that the outcomes using this tool are safer than other means then we should be reassuring the public and changing their negative perceptions.

    The information currently being disseminated to the public as well as to some professionals breeds severe fear and anxiety as well as a very poor reputation for the services and the staff who are supposed to be caring for patients. many people dread a need to be hospitalised or to fall into the hands of the medical and nursing professions for fear of receiving negligent or harmful care or their needs and wishes, or those of their relatives or other representatives, not being heard or taken into consideration.

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  • anon 3.21 - do you have much experience of using the LCP?

    You say many people dread a need to be hospitalised, have you looked after patients who dread being in hospital, I haven't.

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  • Anonymous | 10-Jul-2012 6:49 pm

    from anon 3.21

    I would throw some questions on this topic back to you.

    Have you read the articles in the press this past week which are what in general inform the general public, scare mongering though some of them may be, in addition to their own experiences of people they have known who were put on it? Who knows how much is editorial licence of the press and how much is the reality. The fact is, this is what the public believe and is the focus of their concerns.

    have you looked at all their comments? a very large number of these express a great deal of uncertainty, misconceptions and confusion as well as anxiety and genuine fear that if they are hospitalised they may have no choice but to be put on the LCP, which in its turn is believed by them to remove to their elements of choice. Such comments cannot be ignored and there is little point in defending the use of this tool without acceding to their right to be better informed about the benefits as well as the pitfalls of healthcare staff using this instrument which is only as good as those using it if they are to have confidence in the LCP and dispel the belief that this end of life care pathway is being used to cut costs.

    "Deadly one-way street

    Tens of thousands of patients with terminal illnesses are placed on a “death pathway” to help end their lives every year. However, in a letter to The Daily Telegraph, six doctors warn that hospitals may be using the controversial scheme to reduce strain on hospital resources."

    http://www.telegraph.co.uk/comment/letters/9385681/Deadly-one-way-street.html

    "Hospitals 'letting patients die to save money’"

    http://www.telegraph.co.uk/health/healthnews/9385674/Hospitals-letting-patients-die-to-save-money.html

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  • Anonymous | 10-Jul-2012 10:13 am

    It seems there is a misconception in the media and among the public of the LCP.

    I would further venture that there is a misconception about the LCP among medical and nursing staff. Far too often I have asked a Dr about implementing the LCP and they freeze, terrified that it equates to signing a death warrant. This is not the case and I believe far more needs to be done to educate staff about the LCP.

    I would rather the LCP was implemented when a decision has been made to withdraw treatment, for example - I work on an ICU and have seen the withdrawal of treatment, followed by a visit from SNODS only to find out when I returned to work that said patient did not die within the window of time that would allow harvesting of organs and instead was discharged to a ward where she still did not die! Now, to me, this patient ought to have had the LCP implemented - just becasue it is, does not mean it cannot be halted. It is good for a year. Not every deterioration is permanent or irreversible surprisingly.

    It would do the family good to know that at least there was a safety or comfort net to protect their loved one during uncertain times - particularly when being transferred from place to place, sometimes with different staffing levels.

    At the moment, all I see is distress, confusion and a certain lack of decision making capability on behalf of medics.

    As for the matter of cost effectiveness, I must believe and explain to relatives far too pften that the decision to acknowledge End of Life is never taken lightly and is ultimately and fundamentally concerned with the patients comfort and dignity - unfortunately, the setting for this is rarely ideal but that's another can of expensive worms no doubt.

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  • michael stone

    This is moving into an area of law which is complicated and very muddled within existing guidance. At the risk of attracting a huge 'attack' here, the law does not seem to allow for 'compassion as a reason to withhold life-sustaining treatment' (see section 4(5) of the Mental Capacity Act and its interpretation in the MCA Code of Practice, if anyone thinks the Code is worth reading {from a legal standpoint}).

    But - and I'm not debating what is 'right' here, I'm commenting on what the law appears to say - as it happens, 'We are not going to try and keep you alive, because doing that costs us too much' appears to be perfectly legal for the INSTITUTION/SYSTEM to say(if it were not, how could NICE exist for drugs which are life-sustaining ?). Probably not for individual doctors and nurses, but for the NHS as a larger concept.

    The easiest situation, looking at it legally, is if you have explained the options to the patient, and the patient has said 'I refuse that treatment/option', but even then it becomes very muddled, if the patient loses mental capacity, because (again) the guidance surrounding decision-making for patients who have lost capacity, is very muddled and ambiguous.

    People should be allowed to die, in my opinion, without any discomfort which could be relieved if they ask for relief of that discomfort - I think what must always be done, is what the DH spokesman said;

    'The decision to use the pathway should involve patients and family members, and a patient’s condition should be closely monitored.'

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  • My father recently died in hospital at the age of 84 on the LCP. Reading the story in the Guardian this week really upset me and, for a moment, I wondered if the doctor and nurses had been wrong to adopt this approach. Should they have done more?
    Then I thought about how ill he'd been for so long, how many antibiotics he'd had, the catheterisation, the lines in, the tests on and on.
    The renal consultant had told me and my mum that Dad has simply run out of steam and to keep 'doing' things to him wasn't going to prolong his life but merely prolong the process of dying.
    For us it was dreadful experience to watch him slip away but the staff who cared for him in that final week on the LCP were diligent, kind, thoughtful of our needs and when he final died they were very supporting. I hope other families who have been through the LCP don't now start doubting the care their family member received because of this news story.

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  • My brother who has pancreatic cancer was in hospital having been admitted from home. He was unconscious and when I arrived at the hospital the consultant told me he had had a cerebral event and he was in renal failure. I noticed he had a cough reflex and his arms and legs were moving spontaneously. He started talking when I talked to him whilst changing his sheet. I started giving him fluids, he came round started drinking and eating. He had a duodenal stent put in and is at home with his 3 children. My brother is 48 years old and he would have died on the LPC if I hadn't rushed home to my home town.
    One size doesn't fit all and Drs aren't always right. I've been a nurse for 40 years, this LPC scares me. How many people like my brother have died?

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  • There have been many untoward events in recent times ranging from the Stafford disaster to the death by neglect of 22year old man in a London teaching hospital. There have been scandalous events involving the care of elderly people and miscalculated doses of medical given to neonates. Maternity
    patients have not escaped either.

    The media understandably have jumped on these issues and have succeeded in generated much public debate. Nurses and Doctors , as a result of this media storm, no longer enjoy the unquestioning confidence of the public.

    Until the NMC's "Code of Practise" is adhered to ( in the case of Doctors ---the GMC's "Good Medical Practice" guidelines) public confidence will continue to be eroded.

    The public debate involves more than anxiety about the use of the LCP but demonstrates fear about what actually happens to people once they are hospitalised. (ie. Will I or my relative be exposed to neglect and incompetence? will I be "allowed" to die?)

    Anonymous 7:56 who claims to be a Nurse tells a story which will without doubt, now published, will reinforce the public's opinion that Doctors and Nurses are not worthy of trust.

    The caring professions are facing a huge challenge, regaining the public's trust will not be easy. A start can be made if each Nurse and Doctor made a determined effort to stamp out all bad practice.

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