There are fundamental problems with the Liverpool Care Pathway

Yesterday afternoon MPs debated (full text) the Liverpool Care Pathway (LCP) in Westminster Hall, which serves as a parallel debating chamber of the House of Commons. The debate was moved by Glyn Davies MP, who described himself as a supporter of the LCP. Mr Davies and many of the other speakers in the debate were anxious to save the reputation of the LCP following much recent negative media reportage. Most MPs in the debate repeatedly reassured each other that the LCP itself was not the problem, but rather bad practice of the LCP and/or 'sensationalist' and 'alarmist' stories in the national press. There was little recognition that experts who have spoken out about the LCP have said that the problems with the LCP are fundamental. It is those fundamental problems, not bad practice of the LCP, which are to blame for the scandals which the media has brought to light.

Here are some of the fundamental problems and systemic issues with the LCP which experts have highlighted:

• The central requirement for starting the LCP is that the patient is in the last hours or days of life, yet doctors' predictions that someone is going to die imminently are almost certainly frequently wrong. The pathway leads to a suspension of evidence-based practice and the normal doctor-patient relationship.
• The LCP has a machine-like efficiency in producing death. As the LCP entails progressively increasing doses of a sedative and a narcotic, improvement in the underlying illness may be impossible to detect.
• Any chance of recovery may be jeopardized by high doses of narcotics recommended by the LCP, which may also be lethal.
• The moral obligation to supply fluid to the dying who may experience thirst - part of basic care - is being flouted under the LCP.
• Doctors are being pressurized to participate in the LCP even when they feel very uncomfortable about it, being told that the LCP is national policy. Some doctors are losing control of the clinical care of their own patients.
• The practice of terminal sedation, involving continuous sedation and cessation of fluids, cannot be justified under the principle of double effect. The prognosis of imminent death may well be a self-fulfilling prophecy. The LCP's combination of narcotics and dehydration is ultimately lethal. In many cases it appears that there is a deliberate intention of hastening death
• The LCP is usually applied without the knowledge or consent of the patient. The lack of assessment of mental capacity of patients and the lawful obtaining of informed consent are serious concerns.
• There is little point in reassessing at four hourly intervals if the patient is in a state of drug-induced unconsciousness. No one should be deprived of consciousness except for the gravest reasons.

Today a parliamentary answer on the LCP from Earl Howe, a health minister, was published. Among other things he said:

"The LCP is not a treatment but a framework for managing treatments. Consent is therefore not required for the LCP itself, but normal consent rules apply to treatments while someone is on the LCP."

However, as is clear from the evidence coming to light - the testimony of over 400 people and rising - patients and/or their loved ones are frequently not informed that the patient's treatments are being managed under the LCP. It is the LCP's modus operandi regarding prognosis, medication and hydration which is causing the widely-reported high number of premature deaths. It is misleading to claim that the LCP is not a treatment and just a framework when in fact it is a treatment protocol.

Also today, The Telegraph reports that Dr Bee Wee, president of the Association for Palliative Medicine and a supporter of the LCP, as saying that the cases which have come to light suggested that “packaging up” principles used in hospices for hospitals had caused difficulties.

The Telegraph also quotes Professor Irene Higginson, of Kings College London:

"What we don’t know really is whether it is the way that the LCP is being used and the environment that is in or whether it is something within the LCP which has confused people or made them use it in a way which doesn’t work so well.”

These are tacit admissions that there may be fundamental problems with the LCP. I am grateful to Bishop Philip Egan, the Catholic bishop of Portsmouth, who issued a pastoral teaching message about the LCP early last month, in which he wrote that there are good

"reasons for a careful re-evaluation of the LCP and its application in practice."

Should not then the use of the LCP be halted?

Comments on this blog? Email them to johnsmeaton@spuc.org.uk
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