Friday, 26 October 2012

Liverpool Care Pathway for the Dying: Part 1 - Assessment

According to the Daily Mail, there is to be a review of the LCP following complaints by relatives who did not know their loved one had been place on the LCP. However as the above article also implies that the LCP is a form of institutionalised euthanisia, whereby "patients judged to be dying are left without treatment, food or fluids" I am inclined to be a little skeptical, because I have actually read the LCP guidance and it doesn't say that. But what it does say is that firstly, the LCP "does not replace but supports clinical judgement" and secondly that the LCP is "only as good as the people who are using it". In fact it states that the pathway should not be used without education and training. Interestingly, it also states that the "death [of dying patients] must not be considered a failure; the only failure is, if their death is not as restful and dignfied as possible".

A quick look at the Catechism gives the following (annotations my own):
2276 Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible.

2277 Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.

Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator.
The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded.

2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted.
The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.
The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable.

Palliative care is a special form of disinterested charity. As such it should be encouraged.
So what does the LCP actually say?
1. Deterioration in the patient's condition suggests that the patient is dying. At this point there must be an assessment by the multi-discplinary team (MDT).
2. The patient is deemed to be dying from non-reversible causes and in their last days or hours of life. Specialist referral may be sought.
3. The patient's relatives/carers are informed that the patient is dying. The care plan, including the LCP, is discussed. 
4. The LCP is implemented. This includes ongoing regular assessments.
1-2. It is hard to tell if a patient is dying. It is even harder to say if they are in the last days or hours of their life. The LCP takes steps to address this by requiring an assessment to be made by the MDT. However, especially at weekends (and at night) the MDT may be somewhat thin on the ground...there will be nurses, there will be junior doctors, but the number of senior doctors is probably low and there are unlikely to be any other health-care professionals around - pharmacists, physiotherapists, speech therapists (who carry out assessments of a person's ability to swallow) etc who would normally be considered a legitimate part of the . I once worked with a GP who joked one day that Mrs X was ruining his reputation. The extremely elderly lady in question was in a care home, and was barely eating or drinking. He informed Mrs X's family and they gathered round her bedside...six weeks later she was still going strong. I have seen deteriorating patients unexpectedly recover, and recovering patients unexpectedly deteriorate and die. I would not consider myself competent to make this decision. So on paper we have no problem, but in practice we have a big question mark over 2277. Not because the intention of the LCP is to hasten the death of the patient, but because if a patient is wrongly placed on the LCP then it will hasten their death, not because of the intention, but because of the act in itself.
3. The LCP emphasises that it's not just about telling the family that the person is dying, it's about helping them to understand this. This will probably take a while to sink in. The guidance says that the care plan should be "discussed". Although not stated, this should include consent, because consent is required in UK law. Treating a person without consent would make you liable for assualt and battery. However, consent must be informed, which requires competence (ie the capacity to understand the situation and give that informed consent) on the part of the person giving or refusing it. If the next of kin (assuming the patient themselves is not competent) does not understand that the person is dying, then technically they are not competent. The level of competence required varies from case to case, from illness to illness and treatment to treatment. Also refusal of treatment requires a higher level of competence than acceptance (for example, children under 18 can overrule their parents and consent to treatment if they are considered competent, but however competent they are they can never overrule their parents and refuse treatment).  But the LCP involves discontinuation of some medications and initiation of others, so I am not sure what level of compentence would be required. This is in accordance with the second part of CCC 2278.
4. There have been stories of patients being on the LCP for weeks or months. This should not happen because the MDT should re-assess the patient every three days OR there is any improvement which suggests the patient is not imminently dying (there's a list) OR the patient, relative, carer or "team member" expresses concern about the plan. He we have an ambiguity over what is mean by "team member": does this mean a member of the MDT in general, or the specific group who originally assessed the patient? I think it would have to be the former, ie any healthcare professional who is involved in the care of the patient. Now communication becomes key. Too often, healthcare professionals communicate by writing in the patient's notes. Surgeons have the worst writing, and pharmacists usually the best (they suffer a lot from other people's bad writing). If the patient is very ill then there may be several pages of nursing notes between each assessment by anyone else, always supposing they are in the same place as the medical notes. And I have even seen a note saying "Dear Dr Y (the specialist consultant who had been called in to review the patient), Thank you for seeing this patient and for the plan. I have carried out 1 and 2 but I can't read 3" or words to that effect. I have no idea if this specialist was going to be coming back to the patient. Was he going to see this note? In this case it probably wasn't an emergency because it was point 3, not point 1, and the doctor left instructions, rather than implementing 3 himself.
The 3-day rule is a good one: if the patient has been diagnosed as in the last hours or days of their life, and the MDT come back after 3 days and the patient is in the same state as before, then frankly I think you need to question your initial assessment.

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