Liverpool Care Pathway: A way of death worth fighting for?

It has been denounced as 'euthanasia by the back door'. Now specialists in palliative medicine are defending its use

It was developed as a measure to help ease the suffering of the dying. Instead it is alleged to have introduced “backdoor euthanasia” into the NHS, leading to the early deaths of tens of thousands of patients in return for millions of pounds in “bribes” for hospitals.

Specialists in palliative medicine have hit back at critics of the so-called Liverpool Care Pathway, a checklist devised to help hospital doctors and nurses assist patients to a humane, dignified and pain-free end. They argued that its aim was to enable patients to “live until they die” – freed from the paraphernalia of tubes and machines that can increase distress.

The measure, developed over a decade ago by palliative care specialists in Liverpool, has become embroiled in controversy in recent months, as some doctors, religious leaders and pro-life groups have alleged that patients are being put on the “pathway to death” without their consent or that of their families in response to financial incentives from the NHS. The Daily Mail has run a campaign claiming hospitals are being bribed with millions of pounds to send patients to an early grave.

The publicity has worried families and even led to dying patients refusing hospital admission because of fears about what would happen to them, experts said today, describing the development as “tragic”.

Norman Lamb, the Care minister, announced an independent review of the measure in November after an audit showed a significant minority of patients and their families were unaware they were being put on the pathway.

An estimated 350,000 patients with chronic illnesses need palliative care each year but fewer than half (170,000) receive it, of whom 130,000 are placed on the pathway.

The audit last year by the Royal College of Physicians and Marie Curie Palliative Care Institute in Liverpool of 178 hospitals found 44 per cent of patients who were conscious and a third of families were not consulted before the decision was taken.

Jeremy Hunt, the Health Secretary, condemned the failure to consult as “utterly unacceptable.” But he defended the Liverpool Care Pathway as a “fantastic step forward”, adding that “one or two mistakes” should not be allowed to discredit it. The independent review has been stalled for six weeks while ministers have sought an independent chairman. Dr Bee Wee, president of the Association of Palliative Medicine, said an announcement was “imminent,” and the review was expected to report later this year.

Dr Wee admitted the checklist had been misused in hospitals which did not provide training and support. “Clearly there are some situations in which care of the dying is not as it should be.” Telling a family their relative was “on the LCP” was being used as a euphemism for “dying” by staff who found it hard to broach the subject. Dr Wee said that was unacceptable. “This is about better training.”

The challenge was how to prevent the LCP being used as a tick box exercise. “It provides a check-list for care of the dying for non-specialists. It tells them: ‘you need to think about this’. But some people stop thinking and just do the list,” Dr Wee said.

That had led to problems such as the abrupt withdrawal of artificial feeding and hydration, leading relatives to claim patients were put to death.

The LCP says a blanket policy to withdraw artificial nutrition and hydration would be “ethically indefensible”. But artificial feeding is defined as “treatment”, similar to treatment with antibiotics, and may be withdrawn where it is in the best interests of the patient.

Hospitals have received bonus payments related to the number of patients placed on the pathway, amounting to an estimated £30m. The payments are intended to encourage good quality care, by ensuring patients are being looked after appropriately at the end of life and not being aggressively treated. The Department of Health insists the payments ensure dying patients are “treated with dignity” but the revelation of the payments has aroused fears they may provide a perverse incentive.

Professor Irene Higginson, a palliative care specialist at Kings College, London, said today that good palliative care could extend life rather than shorten it. A US study had shown cancer patients lived two-and-a-half months longer with better quality of life and lower costs than those who received standard care.

The experts said busy hospitals were not good at dealing with the dying, where the raison d’être was to deliver cures, and death was evidence of failure. The LCP existed to protect patients from being treated aggressively when they were beyond help, and from being neglected when they needed care.

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