Monday, 4 February 2013

Liverpool Care Pathway update #1

Given recent events [more later] I urge all Catholics to research into the present situation regarding the Liverpool Care Pathway & its grave potential for backdoor Euthanasia.

Here's a recent argument I had with a very sincere Catholic Doctor on the Catholic Herald:

I am a cancer doctor and Catholic. To call the LCP euthanasia is completely wrong, and to imply that I commit a crime every day of my life I find deeply upsetting and offensive. I entered the medical profession, like most of my colleagues, to care for patients, and every day I believe i make the best decisions I can. I do not presume that i am always right - managing a patient who is dying is never easy - but I am never motivated by targets or bed needs - I am motivated by doing the best for the individual who needs help at that time. I have been asked by patients and relatives to expedite the death of a dying patient, and of course have always said that this is illegal and wrong, but I assure you it is always very difficult to watch these patients suffer and die a slow death. However, I have started countless patients on the LCP and have NEVER regretted it - it is simply a tool to help us identify early and manage the symptoms of dying and is the same as would be done without the LCP; simply more stream-lined and hopefully saves needless suffering e.g. in waiting for a doctor to prescribe a pain killer etc. Patients are never needlessly sedated and, if they are conscious, are able to eat or drink as they can, but I would strongly discourage any attempt to artificially feed a patient who is dying - having a tube put down your nose into your stomach is extremely unpleasant and completely inappropriate if someone has little time left to live. The priority should always be quality of life, not quantity. When it is my time to die, I hope that the LCP still exists as it is what I would want for myself. Death is inevitable; we cannot delay it forever, and when it approaches isn't it better to treat that person with dignity and good control of symptoms, with minimal needless intervention?

My Response:

Sorry Ma'am but what is your response to the 69,000 the audit revealed out of the 130,000 who were placed on the LCP with neither patient nor family consent nor without any independent second opinion. 
What is your opinion on prognosis based treatment rather than needs-based? i.e. 72hr prognosis permits the immediate removal of nutrition and hydration and the increase of opiate provision to toxic and continous sedation levels - all administered by LCP-untrained medical staff once a clinician or diagnostic team has made its determination? 
As this is a Catholic Newspaper Blog might I remind you that prognosis based treatment is automatically condemned by the 5th commandment, repeated papal teaching and directives have stated that nutrition and hydration are natural forms of care and NOT removable medical treatment and in 1957 Pope Pius XII in his speech to the anaesthetists declared unnecessary sedation in palliative care as barbaric, deplorable and gravely evil. 
Perhaps you are also aware of the necessity of hydration for effectively functioning analgesia? Together with the recommended provision of the anti-nausea/anti-emetic drug hyoscine which is a natural desiccating agent and accelerates dehydration and therefore muscle and organ necrosis? 
Or that Gomes & Trescott proved that high opiate provision for non-cancer patients actually acellerates death rather than merely sedating them? 
To deny that the LCP - even in its normative use within the provision of its 'safeguards' 
[which are ludicrously arbitrary and discretionary - terms such as 'in the patient's best interest' and 'not detrimental to the patient' - phrases which can be interpreted in multiply antagonistic and contrary ways] 

The Response was even less cordial:

This post is completely misinformed and serves to do nothing other than fuel the scaremongering that has occured in the media. You clearly have never had experience of using the LCP and have no concept of palliative care. I am a Catholic Palliative Medicine doctor. I take issue with the statements you have made: 1. the LCP does not permit patients to automatically be put under continuous sedation. It recommends that patients should be prescribed sedatives to be given if they are distressed, with terminal agitation being a prominent feature in dying patients regardless of what condition they are dying from. This would involve administering medications that would ease agitation but not cause a deep continuous state of sedation. so your statement is not correct. 2. The LCP does not permit the use of 'toxic' levels of opioids. It promotes the prescribing of an appropriate dose of opioid analgesia to be use if patients are dying in pain. If patients are getting toxic side effects of opioid medications then they are clearly not tolerating the current opioid precribed and an opioid switch is required. Opioids are used in the management of pain, and have other applications such as their use for breathlessness. They are NOT for killing people. Again, your statement is not correct. 3. Hyoscine Hydrobromide is recommened by the LCP. Its purpose is not as an antiemetic. It is used to aid in the reduction of end stage respiratory secretions, what some call a 'death rattle'. As patients are dying they will naturally have a reduced level of consciousness and respiratory secretions can commonly gather in the upper airways. While this is felt to not be distressing to the patient, family and friends often find it very distressing to listen to this. however, we do not want to risk the chance that the patient is in some way distressed by this, and if secretions are excessive these medications can be very useful. Patients with primary lung cancer or lung metastatic disease can have particularly distressing secretions. It does not radically affect renal function and therefore will have no impact on the excretion of opioids from the patients body. This medication is commonly used in actively dying patients, providing symptomatic relief for patient and providing psychological benefit for the family and friends, your statements about muscle and organ necrosis have no basis under these circumstances and show a lack of insight as to the application of this medication. 4. As for accelerating death with high opiate use...the LCP does not promote high opiate use in opioid naive patients. Patients who are dying and are requiring high doses of opioids are going to be those patients who have been on them longterm, during the course of their illness and such doses have been built up over time. Opioids should NEVER be used for the purpose of sedating patients. This is a misuse of such medications. Therefore if people are using them to sedate patients ofcourse it would lead to accelerated death. This is NOT how they are used in palliative care. 5. finally... 'backdoor euthanasia'. Lets forget the LCP just for a moment. When patients are dying they deserve care and attention. Patients under my care who are dying will be given time from all our staff, as will their family. We will work hard to keep their symptoms of pain, nausea, breathlessness, secretions, anxiety and distress undercontrol, maintaining them in a condition that they can still speak with their family and friends until their body will naturally bring them to a deeper sleep as they approach their final day or days. I do not practice euthanasia. Human life is sacred and only God can give and take it. Human life is valuable and we must treat it with respect. Now if you were to read the LCP you would see that all it does is promote this same care I offer to my patients but it asks doctors who do not do this regularly as they serve patient populations where death is not as common to stand back and ask the questions that I as a palliative doctor ask: should we subject our patient to more blood testing? have I prescribed medicines for pain/nausea/agitation/secretions incase my patient develops such symptoms? Does my patient need fluids? does my patient need artificial nutrition? (YES- the LCP asks us to consider if they are needed/if they should be continued/if they should be stopped). To continue IV fluids in a patient who is dying will only serve to increase the risk of developing respiratory secretions that I have spoken about already. A Cochrane review on the use of articial hydration in dying patients has provided NO evidence that IV fluids has any influence on survival in dying patients, you should read it. It is sad that a Catholic doctor commented here (Carolynnscrim) giving her experience and it was met with such a response. We need to trust in the people who are dealing with this difficult issue and who have an expert knowledge of the subject - through all the media hype the experts are being drowned out my sensationalists. The LCP is there for promote good palliative care. The examples cited in the media sound like patients who may not have been placed on it. It highlights a need for investment in palliative care provision and training of staff. It should not serve as a frenzy for scaring people about euthanasia and adding to the distress of dying patients and their families that I am seeing in my work. 

My reply:

1. Adam Brimelow's BBC Radio4's "The Report' of Aug 9 revealed the widespread use of Continuous Deep Sedation in British hospitals and its euthanising potential as experienced in Dutch hospitals
Rather than being a 'prominent feature' among the dying Dr Nigel Sykes determined that CDS is only necessary for around 0.5% of all terminally ill patients - yet it is estimated to be responsible for 18% +/- 2.5% of all hospital deaths? 
So for every 36 patients paced in CDS - 35 shouldn't have been! 
Your statement is thus incorrect. 

2. Prof Anthony Cole of the Medical Ethics Alliance has stated his grave concerns over Opiate toxicity levels when aggravated by dehydration - " In the MEA view there are hardly any circumstances where fluids need to be withdrawn, opiates become more toxic, consciousness is impaired and the suggested doses are too large for the frail elderly". 
I have already mentioned Gomes & Trescott studies which reveal opiates are accelerating death for non-cancer patients [thus directly contradicting and disproving the stated opinion of the BCEW document on care for the dying] The Catholic Medical Quarterly of Aug 2011 will confirm this. 
So I'm sorry your statement is [yet again] incorrect. 

3. You did not confirm that Hyoscine [hydro & butyl - bromides] is indeed a desiccating agent as is Glycopyrronium - and Haloperidol - and Levomepromazine - and Cyclizine - and Metoclopamide - and Octreotide - all permissible by the LCP - every single one accelerates dehydration - A yes or no would suffice. 
All these drugs' and Opiates' effectivity and their bodily concentration levels are seriously aggravated by dehydration - yes or no? 
I was referring to the effects of long-term dehydration

- something you failed to consider while attempting to misdirect by explaining Hyoscine's usage and application - rather than the plain and simple fact that it also accelerates dehydration. 
Therefore your answer is neither correct nor incorrect - you shirked from answering it! 

Might I also enquire, as you've already mentioned lung cancer/metastatic disease, why the LCP recommends the use Midazolam for the treatment of restlessness and confusion when any pharmacopoeia will strongly warn against its usage in lung patients as it could potentially kill them!!! 

 4. Could you please cite from the LCPv12 where there are any safeguards to ensure that opiate-posioning is not occurring in the patient? 
There is a cautionary recommendation to reduce opiate levels if renal function is seen as severely compromised - but there are no mandatory tests performed for morphine-6-gluconoride which would indicate opiate poisoning 

[in fact virtually all normative tests are deemed 'unnecessary' and are immediately halted once the 72hr prognosis is decreed] 

and myoclonic jerks can be hidden behind both delirium-incoherent spasmodic reactions and sedation. 
I'm sorry but you have no way of determining what levels are required for analgesia rather than following the opiate levels advised in the British National Formulary or directly from the LCP. 
In other words there are no provisions or safeguards for determining that opiates are not poisoning the patient.
...and they inevitably will be too high for some patients - but the tests and monitoring to indicate this is happening - is halted!!! 
So yet again your claims are incorrect. 

5. I have cited Catholic teaching on the issue - if you decide that you wish to remove the Church-decreed natural care - appealing to the equivocation that the dehydration is not accelerating death, it is rather preventing respiratory secretions - I call you out as as being economical with the truth to the point of grand larceny - you are fully aware of the consequences and yes I have read the Cochrane 2008 and 2011 updates where although you are quite correct in your correlation of hydration with secretions - hydration also significantly reduced sedation and myoclonic jerking 
- and what are these symptoms of? 
erm Opiate posioning!!! 
Cochrane does not say what you say it does. 

The LCP most definitely does not conform to Catholic teaching in three major areas, the removal of the natural care of nutrition and hydration; gravely immoral unnecessary sedation by opiate over-use... 
...and the big one - signing the death warrant with a 72hr prognosis and actuating a prognosis-based care system rather than a [provisionally reversible] needs-based one. 

What's more sad is that a Catholic Doctor is misdirecting, misleading and misrepresenting what is happening in the LCP - what its 'safeguards' actually prevent and what they permit...

I don't particularly care if you are treating your patients well...

I care more that the LCP is ensuring that you MUST treat your patients well..
...and if it's allowing any arbitrary, discretionary practice which will accelerate the death or even directly cause the death of the patient? 

You know what the answer is; however unpalatable... 

...ultimately we are confronting a financially-induced backdoor euthanasia - genocide of our terminaly ill!

1 comment:

White Wolf said...

There is no question remaining that the LCP is indeed a method of euthanasia, albeit more fitting to the description of passive Euthanasia. You simply cannot deny that any removal of fluidation will not lead to premature death.

It would help a bit if this were acknowledged.

The definition of passive euthanasia is defined as the withdrawal of medical treatment with the deliberate intention to hasten a terminally ill-patient's death.

There is no doubt that is exactly what is happening, you cannot take a way fluids based on around what is mere guesswork and supposition and not hasten death, especially if the patient is left over several days or even three to four weeks.

I say that because no one, can strictly determine the exact time that a person will die, unless they have the finger on the trigger, so to speak.

The LCP is a contra indicator to faith in more than one aspect. Firstly it can be subject to the most horrendous abuse, which then also goes on to take life and there certainly have been a number of cases where survival has occurred when relatives have removed their loved ones from the program.

If that is the case, it would not be unreasonable to ask, how many more cases could there be, how many more doctors have been misguided by the LCP protocol

There is no doubt and can be no doubt that the refusal which some doctors and staff have made to visitors, wanting to administer water and or food, amounts to a plausible determination to lead that person into a death which is premature.

Whilst it is is fact we all die, what we should be ensuring is that a person has as much of their needs met as can be provided. Death nowadays should be as pain free as possible and the patient be kept as comfortable as possible. But that does not amount to overloading someone with drugs. It also worth remembering that people have been known to recover whilst on the pathway. But that is not an argument for the pathway, indeed it is rather an argument that the pathway should not have been used in the first place!

In reality there is no need for any systematic, one size fits all, care programme, we do not in fact need any "pathway." Instead what we need is proper, rational, terminal care, not any programme which can be subject to the most abhorrent abuse and catalogue of errors as the Liverpool Care Pathway has.