This is a long one. Brace yourself.
There has been a furore recently regarding an article the Daily Mail published about the Liverpool Care Pathway (LCP); a palliative treatment plan for people in their last days or hours of life. The basic premise of the LCP is to avoid invasive and uncomfortable testing (blood tests, repeated observations, X-rays etc) and instead to keep people comfortable: physically, spiritually, and in so far as possible, emotionally.
Naturally, the Daily Fail put plenty of tabloid spin on it, the most frustrating of which is the term ‘Liverpool Killing Pathway’. I hope I needn’t explain to you why this is unhelpful of them – I’ve seen plenty of people die and it is not always the idyll of a peaceful shift of planes in your sleep. Impending death can bring with it problems of many forms – skin hypersensitivity causing every touch to be pain, respiratory secretions building up and blocking people’s airways leaving them struggling to breathe, etc etc. Death is not always pretty, and the overriding aim of the the LCP is to remedy this – to use specific treatments and resources to try to mitigate the distress of the dying and their families. It is not just drugs – it is the palliative care team, the bereavement team, the chaplaincy, and further support networks as per the needs of the family and the patient. Death is a very personal thing and you only get one chance to get it right.
On the one hand, I can easily see how the pathway might be abused. It involves withdrawing active treatment in nearly all cases – holding back on the furosemide, the chemotherapy, the immunosuppressants or operations. It involves the use of relatively potent drugs, which combined may have significant sedative effects. It is not the easiest pathway decision to make at the best of times and could be used, in a malicious circumstance, to end someone’s life.*
On the other, I have seen ‘bad’ deaths. Families refusing to allow nursing staff near patients, forbidding the use of any medications including those that would alleviate the patient’s distress. In one case a dying woman who had a heart attack closely followed by a catastrophic stroke died frothing at the mouth, gasping through the secretions that closed her throat while her family refused anything to make her symptoms more bearable. I remember not just the tears of the family in the corridor the next day, but the haggard face of the normally cheerful nurse who was on that night. The LCP is designed to stop that kind of suffering – for patients, for families, and for staff.
There are risks associated with the LCP. Most obviously (as with operations or drug prescription) there is an element of human error. There will always be horror stories, just as there are always miraculous recoveries. As such, I cannot and will not voice a one-size-fits-all opinion on the LCP. What I will do is relate my opinion, based on the experiences I have had relating to the LCP, with respect to this rather more balanced article from the BBC.
The LCP can hasten death. Of this, I am 100% certain. The boundaries of modern medicine are being pushed all the time, and there is much that can be done to trap life in a person. Intensive care can take over the role of multiple organ systems at once; ECMO machines can bypass the lungs, haemofiltration and dialysis can replace the kidneys. All of these things are very invasive and quality of life in ITU is effectively zero. Various powerful drugs can similarly be used to force the body to continue to respond to illness, to fight for life, and the toll in side effects grows with the potency of the compound and the duration of administration. The LCP prevents these treatments from happening, and prevents the distress associated with them (55% of post-ITU patients have psychological issues post-discharge). The patient may not survive so long, but quality of life over quantity of life – what good is surviving 6 weeks of pain and crippling side effects in hospital compared to even a few days of relative comfort in your home? Some people may opt for the former. I wouldn’t, and I wouldn’t want it for my family either.
The LCP can also be misused. It can be started too early, or inappropriately, or not stopped if patients improve. Sadly, doctors do not have crystal balls and we have no way to tell if someone will live or die other than experience and intuition. We work in shades of grey, but when the grey darkens to near-jet I would hope that I have the moral fibre to discuss the LCP as an option, because I’ve seen the difference it can make to people. Ultimately (and I’d like to think I speak for us all even though I know that nothing is absolute) we do what we think is best for the patient because we care. I think the LCP is a good thing. I think it should continue to be used, but equally I think a review of it’s current usage is completely appropriate. Evidence based medicine means you need to collect and refresh evidence, so more reviews are always reasonable. If that leads to an improvement in care, excellent. In the meantime, I will continue to care for any patients I have on the LCP as I would any other.
Opinions and experiences welcome.
*consider insulin, if you will.