Palliative Care in Overdrive: Patients in Danger

Abstract

8 It describes the Liverpool Care Pathway (LCP), a regime that is being promoted throughout the United Kingdom for the care of people dying of malignant or nonmalignant disease in hospitals, care homes for the elderly, private residences, and hospices. The aims are to improve the care of the dying in the community and reduce emergency admissions to overburdened hospitals. The LCP employs traditional palliative care regimes, advocates the use of syringe drivers and powerful medication according to hospice practice, and virtually ignores the hydration debate. This approach is likely to become an integral part of the National Health Service (NHS) End of Life Care Programme unless wiser council prevails. Changing Gear 2006 includes a table apparently taken from a publication by the National Institute for Health and Clinical Excellence (NICE), whose representatives consider it "best practice" to make decisions "to discontinue inappropriate interventions, including blood tests, intravenous fluids, and observation of vital signs in the last hours and days of life." 9 The National Institute for Health and Clinical Excellence is an organization with a nasty habit of prohibiting the use of various treatments in the NHS on the basis of a cost/benefit analysis. This may suit politicians and economists, but it raises ethical, medical, and legal dangers that must not be ignored. Lo and Rubenfeld 10 have stressed that palliative sedation must be carefully distinguished from euthanasia. If correctly used, it can be justified as a last resort if certain criteria are met, namely that intolerable symptoms cannot be relieved in any other way, the patient is at the point of death, and the intention is to relieve symptoms, not shorten life. 10 The LCP is unlikely to fulfill the Lo and Rubenfeld criteria in all cases, for it could well make death under palliative sedation the norm rather than a last resort. If that happens, we will be only a From Medical Ethics Alliance (UK), United Kingdom.

Food or medicine: ethnic variations in perceptions of advanced cancer patients and their caregivers regarding artificial hydration during the last weeks of life: Table 1

“…[7, 16] In a previous manuscript, our team reported findings from a qualitative study describing the meaning of hydration for terminally ill cancer patients in home hospice care and their primary caregivers enrolled in the clinical trial examining the efficacy of parenteral hydration compared with placebo. The overarching themes that emerged from the phenomenological interviews were “hope” and “comfort” – hope for improved symptoms, quality of life, and dignity and comfort associated with the control of pain and shortness of breath, for instance.…”

“…[3–5] Withholding fluids at the end-of-life, indeed, is believed by some to hasten death and to be morally abhorrent [4, 6] as water and fluids are frequently equated to human rights. [7] On the other hand, traditional hospice philosophy recommended restricting AH believing that dehydration enhances comfort as part of the normal dying process and that AH may lead to unwanted symptoms, prolonged suffering and an overly medicalized death. [8, 9]…”

The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

“…One contribution 81 was from a retired British geriatrician, Gillian Craig, who was at that time the Vice Chair of the ‘pro-life’ Medical Ethics Alliance c . Craig supported Treloar’s original description of the LCP in relation to continuous deep sedation, and mirrored the content of her own opinion piece warning of the dangers of rolling out palliative care at scale, which had been published in the official journal of the American Academy of Hospice and Palliative Medicine 82 .…”

The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

“…One contribution 79 was from a retired British geriatrician, Gillian Craig, who was at that time the Vice Chair of the ‘pro-life’ Medical Ethics Alliance c . Craig supported Treloar’s original description of the LCP in relation to continuous deep sedation, and mirrored the content of her own opinion piece warning of the dangers of rolling out palliative care at scale, which had been published in the official journal of the American Academy of Hospice and Palliative Medicine 80 .…”

“…The letter, which echoed concerns expressed in the clinical press by Craig a year earlier 79, 80 , was published a week after the appearance of a report from the Patients Association 84 estimating that up to 1 million patients had received poor care in NHS hospitals, creating fertile ground for media and wider public interest. The authors of the letter noted the Patients Association report and immediately voiced their concerns that:…”