The LCP Continuous Quality Improvement Programme incorporates the following aims:
- AIM To improve care of the dying in the last hours or days of life.
- KEY THEMES To improve the knowledge related to the process of dying. To improve the quality of care in the last hours or days of life.
- KEY SECTIONS Initial Assessment. Ongoing Assessment. Care after Death.
- KEY DOMAINS OF CARE Physical. Psychological. Social. Spiritual.
But with all good things, it is open to abuse. Disquiet is in the air. Adrian J. Treloar, physician expressed concerns' in the BMJ here in 2008 and Ronald J. Clearkin here in May of this year. Prof. Peter Millard, Dr. Peter Hargreaves et al wrote to The Telegraph here in September last year.
The LCP is a tick box document despite Marie Curie's insistence that it is not. The following criteria must be met before commencing the LCP: the patient must be bed-bound, semi-comatose, only accepts sips of fluid and is unable to take tablets. I have read over and over again while researching that diagnosing dying is not always easy.
Prof. Millard et al raised the following points in their letter:
"Forecasting death is an inexact science."
"If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death."
"... the diagnosis could be wrong."
"It is disturbing that in the year 2007-2008, 16.5 per cent of deaths came about after terminal sedation.
Experienced doctors know that sometimes, when all but essential drugs are stopped "dying" patients get better."
Please note: The total number of people receiving continuous deep sedation is twice the rate of the Netherlands where there exist a culture of a casual approach to death and legalised euthanasia. At times, is the LCP euthanasia by the back door?
WHO IS PLACED ON THE LCP?
In 2009 a survey by the Royal College of Physicians and the Marie Curie Palliative Care Institute in Liverpool obtained details of almost 4000 treated on the scheme in 2008 and found:
The average age was 81 and they were typically on the pathway for 33 hours.
39% suffered from cancer, while others had conditions such as stroke, organ failure, pneumonia and dementia.
More than a third were given sedatives and four out of five did not need intravenous meds or fluids - or had them withdrawn,
28% of relatives were not informed that their loved one was on the pathway.
However, this survey found the implementation of the pathway encouraging, highlighting only that information - or the lack of it - given to relatives needs addressing.
CONCERNS REGARDING THE INEXACT SCIENCE OF FORCASTING DEATH
Please read the following two articles: one two . There are several more stories on timesonline but unfortunately they won't 'save.'
When our residents are admitted to hospital, it is mostly with a diagnosis of pneumonia. As said in my first post on Anticipatory Care Planning - forecasting who will placed on the LCP is almost an exact science in my work place! Will they end up on the LCP or won't they? It depends very much on the support system of relatives; if your relatives are strong and will fight for you - it is doubtful that you will end up on the pathway; if your relatives are compliant and open to suggestion or you have no NOK - the odds are you will be placed on the pathway; if you have behavioural/management problems - you will be sedated and thus will cease eating and drinking and will be placed on the pathway; if you can't feed yourself and have no strong support from relatives - you're screwed!
If any of the aforementioned applies and you are young - the odds are you won't be placed on the pathway. Being old definitely works against you.
Prof. Peter Millard has said: "The risk as this is rolled out across the country is that elderly people with chronic conditions like Parkinson's or respiratory disorders may be dismissed as dying when they could still live for some time."
The problem with the LCP is that it focuses on the initial decision as to whether the patient is thought to be dying. If the answer is "Yes" then the entire process becomes automatic. "How can we make you comfortable?" has become "This is how we will treat you while you die." It is an ethical shift.
When used as it should be - and hopefully this is most of the time - the LCP is a fine, wonderful thing. But I fear it has become tainted.