Comment on the Liverpool Care Pathway (2012)
A comment on the Liverpool Care Pathway by Professor David Albert Jones. A pdf is available here.
This Comment is posted with the approval of the governors of the Anscombe Bioethics Centre, but as the Director's personal view, rather than the view of the Centre itself. The Comment is intended to help clarify the complex ethical and clinical questions raised by the Liverpool Care Pathway and to contribute to their eventual resolution.
The Liverpool Care Pathway for the Dying Patient (LCP) was developed in 1997 by the specialist palliative care team at the Royal Liverpool and Broadgreen University Hospital Trust together with the Marie Curie Hospice in Liverpool. The Marie Curie Palliative Care Institute Liverpool (MCPCIL) has led the dissemination of the LCP nationally and internationally as a continuous quality improvement programme to support care in the last hours or days of life. The generic core document of the LCP (MCPCIL 2009) can be found on the MCPCIL website (www.mcpcil.org.uk [clinically assisted nutrition and hydration]
The main principles behind the Liverpool Care Pathway are those of good palliative care and are fully in accordance with Catholic moral theology and with a Catholic understanding of a good death. Nevertheless, in practice it is clear that there is scope for patients to suffer if the LCP is misunderstood and used inappropriately, and the LCP may need to be improved in order to reduce the scope for such misunderstandings. There are a number of pressures that might subvert the proper implementation of the LCP. These might include:
- the subjective character of judgments about how soon someone is going to die, and the lack of explicit evidence-based criteria for this judgment in the case of the imminently dying;
- the influence of managerial pressures to reduce bed occupancy or meet targets of one kind or another;
- reluctance to face the problems of continuing care of certain difficult patients;
- the euthanasiast outlook of some clinicians;
- that rather than assessing, and regularly re-assessing, the needs of the patient, fluids might be withdrawn automatically, where they could, for example, have been useful in alleviating thirst, (in some cases patients have been deprived even of sips of water or of the moistening of their dry mouth);
- Other NHS organizational/ staffing procedures or constraints that may prevent an essential step or dimension of the LCP from being properly applied.
- Lack of discussion with patients (if they are competent) and relatives or carers.
The LCP is not the only approach to improving the quality of end of life care but it has been recommended by the Department of Health, the End of Life Care Programme and by the NICE Quality Standard for End of Life Care. It has also been taken up by a number of other countries (including majority-Catholic countries) and is the focus of international research and collaboration with the aim of improving standards of care.
As with palliative care more generally, the LCP when properly implemented does not aim to hasten death but aims to support doctors and nurses to give the treatment and care that is appropriate for a dying patient and to withdraw any treatments or forms of care that are futile, burdensome, or counterproductive.
The Catechism of the Catholic Church is very clear that medical treatment can sometimes be withdrawn:
The Church has also made clear that pain relief and sedatives may be given where they are needed, even if this reduces lucidity and even if it were to shorten life, though the evidence is that opiates titrated for symptom relief do not shorten life (Sykes and Thorns 2003a; 2003b; Maltoni et al. 2009).
The LCP encourages a system of anticipatory prescribing, so that pain relief is available as soon as it is needed, but both pain relief and sedatives should be given only as necessary to bring symptoms under control. In the United Kingdom and the Republic of Ireland it is not considered good practice in palliative care to aim at producing continuous deep sedation. While sedatives might sometimes be given in excess of what is needed, audit evidence shows that levels of sedation on the LCP have generally been relatively modest and there has been no evidence of continuous deep sedation (Gambles et al 2011). The contrast between the aim and typical outcome of sedative practice on the LCP, and the practice of continuous deep sedation, as used in the Netherlands as an alternative to active euthanasia, is best illustrated by a comparison of the doses used and recommended. This is helpfully set out by Dr Jeff Stephenson, a Consultant in Palliative Medicine based in the UK.
[of the LCP] per hour, with progressive escalation until unconsciousness is achieved, up to a maximum of 20mg per hour
Spiritual Care of the Dying:
There are different levels of ethical analysis of an integrated pathway for the care of the dying: its fundamental rationale; the precise wording of its documentation; the possibility of using it ethically in the best case; the possibility of its ethical use in the typical case (in general or for the most part); the actual pattern of use of the pathway; the possibility of abuse; the possibility that flaws in the pathway might make some kinds of abuse more likely; the further ethical guidance that might be necessary for healthcare professionals in applying the pathway; and the ethical guidance that may be necessary for patients and relatives to mitigate the chance of abuse on the pathway.
This comment has focused on the rationale of the pathway and thus the very possibility of good use. It suggests that the LCP can be used ethically when applied by skilled and ethically committed professionals. Used correctly, the LCP can and does help support the kind of good death for which Catholics pray, a peaceful death that is not hastened but is accepted consciously with faith in God and hope of everlasting life in the world to come.
In regard to the wording of the core documents, while the LCP is already in its twelfth iteration, there are ways in which this wording could be improved further, for example by making use of the wording of the GMC guidance in relation to CANH, and no doubt in other respects. There is more work to be done here.
In regard to actual use, there is certainly evidence of abuse and failures of care of people on the LCP, but such evidence does not show that its use in general or for the most part is unethical. There is more to be learned about how the LCP is being applied in general and how this may be improved and failures avoided. It is to be hoped that the current Department of Health review of individual cases and of systematic data will shed some light on this.
There is thus more work that needs to be done in relation to ethical analysis of the LCP. This comment is intended to help clarify some of the key ethical and clinical questions raised by the pathway in the hope of contributing to the eventual resolution of this complex and important area.
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