Monday, 15 October 2012

The Liverpool Care Pathway is Backdoor Euthanasia - and we have a moral duty to rescue our neighbour.

Remember this face - remember the name - It's Kane Gorny - and he was murdered in his hospital bed.

Now there was public outrage about Kane - but for those tens of thousands being euthanised
in our hospitals by other means and through other circumstances or from other ethical deliberations?
There is silence...130,000 are placed on the Liverpool Care Pathway every year - that is 1-in-6 of all our national dead. 69,000 of these were placed on the Liverpool Care Pathway with neither consultation with the Patient nor their families.

In March 2010 Damian Thompson warned us that Bishops' Conference was rushing through Palliative Care guidelines after a consultation period on the LCP of which nobody was actually made aware!!!
...and even though [despite being vociferously promoted in the draft proposals] the LCP was removed from being directly mentioned in the final BCEW document -  it has been repeatedly promoted and endorsed by Catholic Bishops [more importantly Archbishop Smith], clerics, journalists and professional laity...including an intensive letter argument in the Universe where many senior clergy & ethicists not merely supported the LCP but strenuously dismissed anyone's grave concerns over its practice and even hinted at the reckless irresponsibility of suggesting the LCP may involve euthanasia in that it might play into the pro-Euthanasia lobby's hands....

[with apologies to GKC]
The wisest thing in the world is to cry out before you are hurt.
It is no good to cry out after you are hurt; especially after you are mortally hurt.
People talk about the impatience of the populace; but sound historians know that most tyrannies have been possible because men moved too late.
It is often essential to resist a tyranny before it exists.
It is no answer to say, with a distant optimism, that the scheme is only in the air.
A blow from a hatchet can only be parried while it is in the air.
There exists to-day a scheme of action, a school of thought, as collective and unmistakable as any of those by whose grouping alone we can make any outline of history.
It is a thing that can be pointed out; it is a thing that can be discussed; and it is a thing that can still be destroyed. It is called for convenience "Euthanasia"; and it must to be destroyed.
I know that it means very different things to different people; but that is only because evil always takes advantage of ambiguity.
I know it is praised with high professions of idealism and benevolence; with silver-tongued rhetoric about human dignity, respect and autonomy.
But that is only because evil is always flattering and flattered, as active euthanaisa is called assisted suicide, and abortion is called a 'reproductive right'.
I know that it numbers many disciples whose intentions are entirely innocent and humane; and who would be sincerely astonished at my describing it as I do.
But that is only because evil always wins through the strength of its splendid dupes; and there has in all ages been a disastrous alliance between abnormal innocence and abnormal sin.
Of these who are deceived I shall speak of course as we all do of such instruments; judging them by the good they think they are doing, and not by the evil which they really do.
But Euthanasia itself does exist for those who have sense enough to see that ideas exist; and Euthanasia itself, in large quantities or small, coming quickly or coming slowly, urged from good motives or bad, applied to a thousand people or applied to three, Euthanasia itself is a thing no more to be bargained about than poisoning.


Remember Tony Bland [I strongly urge you to read this by Alison Davis of 'No Less Human'.[Sep 2009]
Now we must all be fully aware of those being diagnosed as in a Persistent Vegetative State may have their nutrition and hydration removed and thus be euthanised in an excruciating, diabolical manner...

..but worse we have to face the fact that euthanasia is already endemic - and
not merely to the physically or mentally handicapped newborn; not merely
to those in PVS, not merely those who have suffered brain damage yet
are still alive without a ventilator; not merely to those who have
demanded their 'rights under the mental capacity act for themselves or
their relatives or those placed in their legal care...

Letter from  Dr Jacqueline Laing, Senior Law Lecturer & director of Juris:

 "The Mental Capacity Act 2005 authorises doctors, in certain circumstances,
to withhold all “treatment”, including food and water, from patients who lack capacity. Importantly, in England and Wales, legally speaking,
food and water administered in a medical environment may be classified
as “medical treatment”.

 In 2008 the Liverpool Care Pathway was recommended as the Department of
Health’s End of Life Strategy and a year later 300 hospitals, 130
hospices and 560 care homes in England had rolled out the programme.

Medical concerns about the very possibility of diagnosing imminent death are
familiar. Where this diagnosis is made, the combination of morphine and
dehydration are likely to undermine a patient’s capacity. Persistent
dehydration of even the fittest sedated patient will kill him. That is
the problem with the Pathway. It reverses the burden of proof so that an incapacitated patient must speak on his own behalf in favour of water.
Even assuming he is well enough, as Kane Gorny’s family found, his pleas may not be heard. The concerns of families, lawyers and healthcare
professionals about this programme demand address.

Healthcare costs, bed-clearing, political Malthusianism and the philosophical
dehumanisation of the vulnerable pervasive in contemporary bioethics are all likely to rationalise bureaucratised homicide."

I'm sorry to say that we are presently in the middle of a
'conspiracy of silence' and deliberate cover-up in regard to the
Liverpool Care Pathway by those who are both advisers to the Catholic
Church & self-confessed 'Catholic ethicists"...

A strong indictment but bear with me:

a] The Liverpool Care Pathway [now on Version 12] contravenes Catholic teaching
[ref CDF & Benedict XVI, Bl. JPII on PVS, Evangelium Vitae etc]
in that Nutrition & Hydration [even by artificial means] are forms
of Natural Care and are not removable clinical treatments.
Even though v12 has ostensible safeguards which may appear to protect a
patient's access to hydration - arbitrary, ambiguous discretionary terms
like 'the patient's best interest' & 'not detrimental to patient'
mean that any clinician, diagnostic team or post-prognosis any of the
medical staff may remove hydration.
Bearing in mind the normative use of Hyoscine as an
anti-nausea/anti-emetic drug for end-of-life patients is also a
desiccating agent - the combined removal of fluids will reduce the
effectivity of pain-relief drugs, will induce excruciating pain as
organs & muscles begin to necrotise and accelerate death by

b] Catholic teaching is categorical regarding the use of opiates as
pain-relief in that it must be needs-based and not unnecessarily sedate
anyone in their final hours. Pius XII in his speech to the anaesthetists
[1957] called unnecessary sedation 'barbaric' 'a
deplorable practice'..'repugnant to Christian sentiments' and ultimately
  gravely evil'.
The Liverpool Care Pathway has prognosis-based opiate provision rather
than needs-based for analgesia. This can lead to unnecessary sedation
and deny the patient the opportunity to die a good, pain-limited,
optimally-conscious natural death. Continuous deep sedation is rapidlybecoming normative practice
c] Not only is this non-analgesic opiate over-prescription sedative in
nature - when it comes to non-cancer patients Trescot[2008] &
Gomes[2011] studies reveal that this unnecessary opiate use actually
accelerates death [thus disproving the cornerstone of the arguments in
the CBCEW end-of-life pastoral care draft & final document]
This directly contravenes the 5th commandment.

d] Holistically speaking as a form of Palliative Care the Liverpool Care
Pathway is irrevocably flawed and directly contrary to Catholic
teaching regarding the sanctity and dignity of human life by a single
- the actuation of irreversible end-of-life procedures after a 72hr prognosis.
To quote a leading contributor to the Catholic Medical Quarterly
"Once you are on the Liverpool Care Pathway you will die; even if you weren't dying!"


Now the President of the Catholic Medical Association is equally as forthright:

and others experts have stated similarly:

Tony Cole, Chair of the Medical Ethics Alliance has expressed grave concerns in that:
a] In the MEA view there are hardly any circumstances where fluids need to be withdrawn, opiates become more toxic, consciousness impaired and suggested doses are too large for the frail elderly
b] There is no provision for truly independent second opinion and informed consent is virtually ignored [as evinced by the audit]
c] There is no required training for anyone applying the LCP [often inexperienced staff].
d] There is no certainty of determining the imminence of death - especially in the elderly with multiple pathologies. There is also very strong evidence for this given the amount of post-mortems revealing death by different causes to the presumed diagnosis.
e]Difficulties will arise in this procedure from a lack of continuity in care.
What is virtually certain is that inexperienced , untrained staff with or without ill-will, will be stopping fluids and giving powerful drugs with lethal effect. Relatives..will be ill-informed, suspicious and sometimes embittered.
The LCP should be used with great care by trained experienced doctors humble enough to listen to a truly independent second opinion. No doubt it has a place in hospices but to roll it out in all settings will lead to MANY premature deaths.
The natural death with consciousness to the end should always be sought for spiritual and family reasons...The LCP does not exclude this but the circumstances listed above will lead to premature unconsciousness, intoxication and hastened deaths.

[Finally Dr Cole leaves us with a devastating prediction]

"Palliative Care itself could be discredited and it could play into the hands of proponents of euthanasia"

In Response Leading Catholic Ethicist & LCP Consultant Dr David Albert Jones said [edited for personal opinions re others and for information not repeated elsewhere by Dr Jones]:

All this said my own view is that the LCP is a good thing both in principle and generally in practice and criticsim of it generally plays into the hands of the euthanasia movement.
It is very clear that if someone is dying then overtreatment is not only unnecessary but probably burdensome and even counter productive.
The LCP aims to give appropriate treatment when someone is recognised to be dying: stopping unncessary treatment, giving pain relief and increasing communication (and spiritual care) with patients and relatives. There is an issue about how to diagnose dying but this is not unique to the LCP, and the LCP recognises assessment every 4 hours - which is more than NHS average even for dying patients.

Furthermore I think attacking the LCP and alleging that euthanasia is widespread helps the euthanasia movement claim that 'slow euthnasia' is already with us so it would be kinder to have fast euthanasia. 
In fact the LCP is not a death pathway and certainly not a euthanasia pathway but is a care pathway for people who doctors are sure are dying.

I do not think there is anything that should be opposed by a good Catholic....I do say that the LCP at least in its latest draft is capable of being used in a way that is fully in keeping with Catholic teaching and I would advise agaisnt using the LCP as a substitute for the real targets of inadequate care of the elderly, failure to respect those with disability and the push for euthanasia (and assisted suicide) by passive and active means.

Really? Let's go back a little...

In 2008 Dr Adrian Treloar wrote to the BMJ

The Liverpool care pathway (LCP) is the UK’s main clinical pathway of continuous deep sedation and is promoted for roll out across the NHS. Rietjens et al’s study highlights some serious weaknesses in its design.
The eligibility criteria do not ensure that only people who are about to die are allowed on to the pathway. They allow people who are thought to be dying, are bed bound, and are unable to take tablets on to the pathway. In chronic diseases such as dementia, dying can take years, but such patients may be eligible. Reitjens et al’s paper shows that GPs often put patients on to such a pathway without palliative care advice. A pathway for general use should minimise opportunities for early or inappropriate use.
Murray et al are concerned that sedation is being used as an inexpensive alternative to assessment and specialist treatment. The LCP recommends sedatives and opiates for all patients on an “as required” basis, even when they are not agitated, in pain, or distressed. An automatic pathway towards prescribing heavy sedatives incurs risks.
Moreover, the LCP recommends setting up a syringe driver within four hours of a doctor’s order. This is laudable, if it is needed. But the pathway encourages the use of syringe drivers even when symptoms can be managed without them.
The pathway doesn’t mention the need for food and fluids. Reitjens et al show that withholding artificial nutrition and hydration is the norm. The LCP’s omission of prompts to reconsider nutrition and hydration may allow serious errors in the care of dying patients. It is not acceptable, as Murray et al suggest, that assessing nutrition and hydration are not part of the pathway.
Sedation is right in some situations. But as Murray et al point out, the anticipated outcome of continuous deep sedation is death. We must learn from Reitjens et al’s observation that continuous deep sedation may replace euthanasia. If the methods and pathways that we use for continuous deep sedation in the UK are flawed, then patients will die as a result of inappropriate use. I hope that the LCP will be reviewed and modified.

After the Shocking report by the BBC's Adam Brimelow [Aug 12] on deaths involving continuous long-term sedation In Sep 2009 Leading experts in the area wrote a joint letter to the Telegraph reporting that 1-in-7 deaths were resultant of terminal sedation followed by Max Pemberton's personal account re his Grandfather

Kevin Fitzpatrick, spokesman for the campaign group Not Dead Yet, said: “It is very worrying that in any situation less than 100 per cent of families are being consulted before patients are being put on the Liverpool Care Pathway. It is a shock for families to find that out.

“In some situations doctors are prepared to do it without consulting families because they think they know what is best and questions arise as to why they think it is OK to do that. Families have the right to know why a loved one is being put on the LCP.”

[From Independent Catholic News 25/3/11 by Paul Donovan]

The president of the Catholic Medical Association, Dr Clare Walker believes that euthanasia is being quite widely practiced in the NHS in an unofficial way.

Dr Walker explained how she is regularly contacted by distressed healthcare professionals and managers who describe their experience of witnessing repeated instances of unofficial, active euthanasia in their local areas. "The standards of medical ethics and of interpretation of existing legislation appear to vary greatly around the country and from one organisation to the next, even in the same local area," said Dr Walker.

One development that has enabled this to happen is the adoption of the Liverpool Care Pathway (LCP). The LCP was developed in Liverpool in the 1990s as a result of collaboration between the Royal Liverpool Hospital and the Marie Curie hospice. The laudable aim was to bring hospice style palliative care for those living out their last hours in hospital. Its main emphasis was to unite professional support in the fields of physical treatment, psychological support, and support for carers and spiritual care. “There is no reason to be suspicious when the LCP is being used in appropriate circumstances to a higher standard of care,” said Dr Walker.

However, the scheme has now been rolled out across the country, with the application depending on widely differing levels of ethical application. “If it is used out of context, then it could be used to the detriment of patients e.g. a patient comes into a resuscitation bay and it is not always clear if a condition is acute and can be treated,” said Dr Walker, who recalls that in some hospitals the LCP has become known as the Lazarus Care Pathway due to the number of people who have been put on it inappropriately, are not moribound and subsequently need to be actively treated.

A colleague of Dr Walker’s did a survey on the basis of crematorium records that found in 23 per cent of all deaths of people in one city placed put on the LCP there had been no definite diagnosis at any stage.

Dr Walker puts many of the problems at the door of a lack of ethics in the application of what at face value is a good system for the terminally ill. It is the application that lacks sensitivity and can often just amount to following protocols.  “The problems come when an idol is made of the protocols. It is the same story with anything if you make an idol of it you lose common sense and critical faculties,” said Dr Walker, who defines the slavish following of protocols as “tick box itus.”

She is worried that younger health professionals will be concerned about straying from the protocols for fear they might offend superiors, this means they don’t develop the acumen required to do the job. “Sometimes, in addition to what is required by a protocol, which tends to assess for a single condition, you have to follow an instinct that there is something else wrong with a patient and there is nothing wrong with that. This is the art as well as the science of clinical practice,” said Dr Walker, who abhors the way that cases like that  of the murderous doctor Harold Shipman have been used to tarnish the healthcare professions …...and undermine the effectiveness of the full range of those acting as advocates for patients.

Since the membership of CMA opened to all healthcare professionals and health managers some 18 months ago, an increasing number of both those directly involved in clinical care and those in administrative roles report overt bullying in favour of targets to the exclusion of good standards of care.

 Dr Walker considers the test for any healthcare professional should be that the level of care being provided matches that which they would expect for one of their own family. 

Paul Tully, SPUC's general secretary, gave his reaction yesterday to Dr Walker's statement:

"We must be grateful to Dr Walker for speaking out about the growing anti-life ethos in British medicine. The practice of euthanasia by neglect is insidious and will lead to more and more pressure for active euthanasia - this is the aim of the pro-euthanasia lobby.

"Intentional killing by neglect has become more entrenched in England and Wales since the passing of the Mental Capacity Act 2005. This was designed to permit doctors to end the lives of certain seriously ill or disabled people by withholding treatment and care - including even food and fluids in some cases. Without water, people die. Although active euthanasia (such as giving patients a lethal injection) remains rare in our experience, passive euthanasia is a major problem.

"Dr Walker rightly highlights the dangers of the Liverpool Care Pathway. The LCP can mean that tick-box medicine replaces proper care tailored to the person. In some places it is used inappropriately - the LCP implies high doses of morphine may be used which are not necessary for all patients, and which can hasten death. In some places it has become feared as a way of getting rid of those who aren't 'dying quickly enough'.

"The importance of having a sound ethical foundation when caring for patients who may be dying, or nearing death, is increasingly evident. It is not only experts, like doctors, pro-life campaigners and chaplains who see the growing disregard and lack of proper care for those who are nearing death. Relatives of disabled or elderly people are often distressed by the way their loved ones are treated in hospitals and care homes. This can range from not getting necessary help with feeding and toileting to withdrawal of vital care, like simple intravenous fluids."

Then the floodgates broke at the turn of the year regarding the LCP - Dr Pullicino's revelations were devastating and filled the broadsheets and tabloids

After Quentin de la Bedoyere's article in the Catholic Herald earlier this year two Doctors were printed in Herald letters:

The Liverpool Care Pathway is becoming a deadly machine
From Professor Patrick Pullicino
SIR – One worrying statistic about the Liverpool Care Pathway (LCP) that is not well known is that in both the First National Audit (2006/7) and the Second National Audit (2008/9) the mean time to death on the LCP was 33 hours. The fact that two large national audits two years apart came up with an identical mean time to death shows that effectively the LCP is a machine. Unless the LCP is quickly discontinued death occurs in less than two days, whether someone has terminal cancer or a potentially reversible condition such as pneumonia.
What is not mentioned in the Science and Faith column (July 27) is that the diagnosis of being “within the last hours or days of life”, which is necessary for a person to be put on the LCP, has no scientific basis. This diagnosis is, in fact, a prediction and as such is likely to be in serious error about 50 per cent of the time.
Although it is possible to discontinue the LCP if the patient improves, it becomes more difficult to detect changes in the underlying illness as a patient becomes more drowsy on the LCP.
Yours faithfully,

By email
From Dr Gillian Craig
SIR – It is right to warn people about the Liverpool Care Pathway (LCP). Those who have produced warning cards have done the public a service. Your report (July 27) was helpful, as was that of Quentin de la Bédoyère (Science and Faith, July 27).
If all doctors were trained in the care of the elderly and had all the time in the world to discuss end-of-life care with patients and relatives there would be less cause for anxiety about the LCP. But given the current pressure on hospital beds and the number of frail, elderly people needing attention, there is a very real danger that some who appear to be dying but have a treatable disorder will be put on the LCP with fatal results.
Count de la Bédoyère mentioned some dangers of the LCP towards the end of his article. These are worth repeating lest they be overlooked:
  • Some medical staff may see death as a benefit for the patient or the NHS. It was suggested that death is sometimes hastened if the bed is needed for someone else.
  • Some healthcare staff will be too busy to follow the LCP protocol correctly.
  • Once on the LCP progress checks may be overlooked until the patient is dead.
  • Some doctors may not involve a multi-disciplinary team or seek advice before putting patients on to the LCP.
  • The importance of hydration was not mentioned in the Catholic Herald articles.

When palliative care first emerged as a speciality in 1987 the only patients who received hospice care were those with pain that was difficult to control or those with significant anxiety about the prospect of dying. All the rest were managed by their GPs in the community or by hospital staff if they were admitted to hospital. Surprisingly few old people needed the services of palliative carers in those days and most died peacefully without the need for sedation or morphine. Syringe drivers were never used on geriatric wards in those days. If medication was needed it was given orally or by injection.

Palliative care is in overdrive and patients are in danger. (For discussion see the American Journal of Hospice and Palliative Care 2008; Vol 25: No 2.) The NHS is fast becoming a death service rather than a health service for the elderly. Attempts are being made to vet potential admissions and send the elderly home before they block a precious hospital bed. Those who are admitted and appear to be dying may be put on the LCP and die within a matter of days. People can no longer be sure that the elderly will be treated well, so great vigilance is needed. Many people suffer long-term distress after watching a loved one die on the LCP. It is surely time to review and reduce the role of palliative care in the NHS.
All these problems have followed the closure of far too many hospitals that cared for the elderly. We now have too few hospital beds to cope with the ageing population. Hospital facilities must be increased and care in the community improved as a matter of urgency, so that more people can remain at home until they die in peace.
Yours faithfully,

To briefly conclude:

a] The Liverpool Care Pathway IS INDEED Backdoor Euthanasia.
b]   Catholic Ethicists, medical and charity quango professionals, senior clerics or Catholic commentators - even pro-Life Activists....are readily, pugnaciously, belligerently defending it as 'not euthanasia' and will dismiss and seek to suppress any opposition to it.

And we have to ask why they wish to close down the debate so immediately and with such force?
Answer: They want to save lives - they don't want Active Euthanasia legislation passing through parliament.

They recognise that
a] If they say the LCP is euthanising it will make it easier for the Pro-Euthanasia Lobby to argue for euthanasia being a regular normative medical practice in the NHS - and thus make Pro-Euthanasia easier to become law.
b] As this is a long drawn-out form of passive euthanasia - a system aimed at reduction in pain and suffering would logically [especially in these days of overriding human rights AND financial restrictions] seek to introduce assisted suicide - direct active euthanasia

Which is why we have at present in this country a conspiracy of silence on the LCP.

A whispering campaign against orthodox Catholic & Christian ethicists , healthcare workers, commentators, activists, bloggers etc - especially those with high positions in the medical profession - who prove categorically and irrefutably that patients are being euthanised and murdered in unbelievably excruciating pain and distress.
...and why?

Because [like Caiaphas] the argument is that it is better for a few thousand to die through use, misuse and abuse of the LCP...
...Than for the law to be changed to assisted suicide and active euthanasia leading to the deaths of millions!!!
This present formal co-operation with evil by wilfully denying the immorality of the LCP , the murder of Patients AND the deliberate campaigning against those who seek to reveal it being backdoor euthanasia ?Is beyond repulsive - it's redolent of silence about the trains going to Auschwitz.

 Peter Williams - executive officer of 'Right to Life' has gone on the record to say "There IS ABSOLUTELY NOTHING WRONG WITH THE LCP" and has subsequently denounced anyone who has opposed the LCP as guilty of - and I quote - 'Unconscionable actions..risking lives and playing into the hands of the Pro-Euthanasia Lobby'

He's not only wrong - he knows he's wrong...and this Utilitarian Caiaphas Corollary stinks!

UPDATES :  Unified Support for the LCP from major institutions and charities via  Christian Medical Comment [Peter Saunders]; The Catholic Herald reports concerns over the LCP by   Archbishop Peter Smith & Bishop Anthony Fisher

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