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'The LCP is only as good as the people who use it'

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12 November, 2012

One of the worst examples in recent history was the hysteria whipped up about the MMR jab, on the basis of highly questionable evidence from a tiny sample of children. This evidence has now been utterly discredited, but not before vaccination rates dropped to dangerous levels.

The latest target is the Liverpool Care Pathway, or the pathway to death as the Daily Mail prefers. A torrent of stories about hospitals being bribed to put patients on the LCP, patients being routinely denied food and fluids, or health professionals being too keen put patients on the pathway and refusing to take them off if they show signs of recovery have bounced health secretary Jeremy Hunt into declaring that the revised NHS Constitution will require patients and or families to be involved in end-of-life care decisions.

Anyone who took the time to read less sensationalist sources – or to look at the LCP documentation itself – would see that the pathway is simply a tool to help health professionals to make the last hours of their patients’ lives as peaceful as possible. It is only to be used in patients who are dying, and any who show signs of recovery can be taken off the pathway. Food and fluids are only withdrawn in specific circumstances where this will reduce patient distress, and patients and families are already required to be involved in the decision-making process.

Of course, like any tool, the LCP is only as good as the people who use it, so it is vital that it is implemented by health professionals who understand its principles and purpose, and who stick to the guidance.

Properly used the LCP is a way of providing the best possible care to dying patients and their families. Attacks on the pathway on the basis of instances of improper us, or presenting opinions as facts will simply lead patients, professionals and families to avoid using a tool that has spared countless people distress in their final hours.

Readers' comments (23)

  • michael stone

    Anonymous | 17-Nov-2012 9:47 am

    I think (unless the patient wants to suffer in this way) that deliberately extending someone’s life, if that life consists only of intense suffering, is grossly inhumane.

    But there is a problem, for dying mentally incapable patients who appear to be suffering, and if treatment might extend their life – because assisted suicide is illegal, and this has been written into the MCA:

    Section 4(5) of the Act states that when withholding a life-sustaining treatment (such as potentially successful CPR) the decision maker ‘must not be motivated by a desire to bring about his death’, and in the Code this is expressed in section 5.31 as ‘The decision-maker must not be motivated by a desire to bring about the person’s death for whatever reason, even if this is from a sense of compassion‘.

    This raises the question, of how does one legally justify DNACPR if CPR might work and the patient is mentally incapable – nobody is allowed to use ‘because he was in obvious agony’.

    I believe there is an obvious way around this, but clinicians don’t like it – because they don’t like the way it defines section 4 best interests decision making. It works like this.

    For mentally capable patients, the process goes:

    1) The clinicians decide what treatments to offer, and then describe the prognoses without the treatment(s) and with them, THEN

    2) The patient considers the clinical factors in the context of ‘his wider life and his own beliefs, etc’ and then the patient either refuses or consents.

    So do exactly the same thing for section 4 best interests, but insert as ‘proxy minds’ the ‘relatives and friends’ of the patient in step 2 – and you (clinicians) ask, describing to them step 1, ‘Can you tell us, what choice he (the patient) would make, if somehow we could ask him ?’.

    Now, it appears that every one of those proxy minds, has arrived at a perfectly defensible section 4 best interests decision individually – so if they do not all agree, the further analysis gets a little tricky. But IF THEY ALL AGREE – if all of the relatives and friends think about it, and all say either ‘He would have refused the treatment’ or ‘He would have accepted the treatment’ (with no ‘I don’t know what he would say’ answers), you THEN take the consensus answer as being ‘Something we can all reasonably believe the patient would have said himself, if somehow he could have answered’.

    Then, if the question was ‘Would he want us to attempt CPR under these clinical circumstances’ and EVERYONE (all the relatives and friends) had answered ‘No’, you argue that your justification for not attempting CPR, is ‘Because we believe the patient would have refused CPR’.


    That gets around this prohibition about being ‘motivated by a desire to bring about death’ – it gets very tricky to see how else you can get around it (‘treatment would cost the NHS too much’ seems legal, but that should be a ‘system’ decision, not one for the individual clinicians involved).

    These issues are touched on in my pdf that can be downloaded from:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/obj=viewThread&threadID=665&forumID=45

    in its final 2 pages, which were just extracted from some of my other documents about EoLC, and in particular about EoL at home.


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  • doctors can consent patients under 'consent form 4' for life-saving treatment. many of us have read and are familiar with the MCA, at the end of the day all we want is the best outcome for all our patients, if that means a peaceful and painfree death then so be it, there is no shame in that.

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  • michael stone

    Anonymous | 17-Nov-2012 4:07 pm

    Can you tell me what 'consent form 4' is, as I have never come across this ? I would like to consider it from a legal perspective, whatever it actually states.

    Almost all of us, want peaceful and painfree deaths for people, and the shame is in preventing that by blindly following tick-box-protocols.

    As I ask in Thinking Clearly no 6:

    Imagine that my father were in hospital, I knew he was ‘dying’ but not necessarily within the next few days or even the next few weeks, and I could see he was suffering a lot.

    It is for my father to judge his own suffering - not me, nor his clinicians.

    So if he called over a nurse and said to her “I’ve had enough of this. If I arrest, you must not attempt resuscitation. Please call my son, so that he can come in and I can explain this to him”, and then he arrested before I had been able to go to the
    hospital and hear this from him directly, I would not expect the staff to attempt CPR - that was my dad’s decision, and if he had made it, they should follow it.

    If he had been at home, and had made the same decision but he had explained it to me as “I’ve had enough of this, and if my heart stops I want to be allowed to die in peace. We’ll sort this out with the GP tomorrow, but if you think I’ve stopped breathing
    before then, let me die in peace and don’t call anyone” then this is still his decision, so if I do not call anyone professionals should not expect me to have called someone.

    I might have doubts about the nurse, but I would have no sensible option except to believe her - ‘the system’ might have doubts about me, but likewise it logically has to believe me.

    The NHS has many ways of upsetting relatives - implying that they are lying without any proof, is definitely one of these ways !

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