Sunday, 28 October 2012

The Liverpool Care Pathway for the Dying: Part 3 - Care after death and Conclusions

It turns out there is quite a lot to say about the LCP!

Part 1 - Assessment
Part 2 - Intervention

Care after Death
End of life care obviously includes care of the patient after death. The LCP states that the patient's remains should be treated with respect and dignity whilst the final offices are carried out. The patient's reglious views should be respected and their possessions should be kept safe. The family should be given written information about what they need to do next and talked to (and given written information) about where they can find support in their grief. On a practical level, the hospital (or hospice or care home) has a responsibility to communicate the patient's death to certain parties.

A lot of concerns have been raised recently (and indeed since its introduction) about the LCP. I believe that it is important to recognise the distinction between the LCP itself and the implementation of the LCP. In itself the LCP is not a bad thing: it ensures the dignity of dying patients and I cannot see that it is against the teachings of the Church.

But, and it is a very big but, the implementation of the LCP evidently leaves a great deal to be desired.
  • Firstly, and most problematically, the initial determination of whether a patient is dying is extremely hard to make, and should not be undertaken by junior staff. In fact, it should probably only be made by experienced palliative care specialists.
  • There are accounts of patients languishing on the LCP for weeks or months. This should not be happening. The protocol clearly calls for regular re-assessment of the care plan and that includes the fact of being on the LCP itself.
  • Consent - there seem to be issues surrounding consent where the patient is unable to consent themselves. There needs to be clarity over who can consent for another adult. And if you have elderly parents or relatives then get a Power of Attorney agreement drawn up before you need one, because once you need one you won't be able to get it (if a person is confused or unconscious they cannot give informed consent).
  • The LCP does not call for a blanket care plan, or a blanket anywhere else. However individual care plans take time, time is money and everyone knows that no-one has got enough. It is quite possible that hospitals (in particular) do not have enough money (or enough palliative care specialists) to properly carry out individual assessments and care plans and it is this sort of thing which leads to blankets all over the place, and heavy sedation.
  • It is frequently heard that patients who cannot feed themselves do not get fed. I have seen this happen (staff frequently took my Grandad's meals away, assuming he didn't want them because he hadn't eaten them. Nobody seemed to realise that he hadn't eaten them because even if he had been able to reach the tray, having not eating for several days he wasn't able to lift the fork to his mouth). It is all very well saying that people should be encouraged to eat and drink but there needs to be someone there to do the encouraging. Protected meal times may help some patients eat more, but they also mean that others end up eating less.
I do firmly believe that the LCP is an important step in itself. It recognises that we are all creatures, that death is an inevitable part of life and that all human beings have an inate dignity, which should be recognised even in dying. It also recognises that talking about death helps individuals and their families to better prepare for it. However, it has a huge potential to be wrongly used, and so it is leading to deaths by neglect or euthanasia and this is completely unacceptable. I don't know what the best solution is at this point, but I do think that Catholic healthcare professionals, and others who support life, and who consider themselves sufficiently competent to do so, need to get on board with the LCP on a case by case basis in order to ensure that it is used as it as intended. However, given the huge problems with its implementation, I also don't think there could be any objection to not supporting it or being involved with it. All health professionals should rigorously question their own competence to determine whether they have the necessary judgement and skills to participate in the LCP, and given that we have an ageing population. I, for one, will be reading up on palliative care and perhaps the year of faith could be an opportunity for those who work in healthcare to form themselves in Catholic medical ethics.

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