TERMINALLY ILL PATIENTS ARE RECEIVING GOOD CARE, SAYS NATIONAL AUDIT
An audit of Care of the Dying covering nearly 4,000 terminally ill patients in over 150 hospitals in England has concluded that use of the Liverpool Care Pathway (LCP) is resulting in high quality care for those who are in the very last hours and days of life. The audit, which was conducted by the Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians and the results of which were made public yesterday, underlines the value of the LCP in providing a framework for decision-making by doctors treating imminently dying patients.
The audit does not support criticisms of the LCP that have appeared recently in the media - namely, that patients who are managed in accordance with the Pathway's guidelines are being heavily sedated until they die or that the LCP is promoting a 'tick box' approach in which doctors sometimes fail to spot where patients show signs of recovery. The audit reveals that two thirds of the 3,893 patients whose deaths were assessed needed no continuous infusion of medication in the last 24 hours of life to control distress caused by restless or agitation and that, of those who did require such infusions, all but 4% needed only low doses. Unlike practices in other countries, such as the Netherlands where deep continuous sedation until death is administered according to a protocol, palliative care physicians in Britain have the skills to ensure that the overwhelming majority of terminally ill patients are able to die peacefully and without any significant sedation.
Commenting on the Audit, Dr Peter Saunders, Director of Care Not Killing, said: "This audit of LCP practice in some three quarters of hospitals in England is reassuring. It confirms that deep sedation of terminally ill patients is rare in Britain and that recent suggestions of its widespread use under the LCP are unfounded. It also underlines that any trusts prescribing relatively high doses of sedatives regularly to dying patients 'need to review their practice'". Professor John Ellershaw, Director of the Marie Curie Palliative Care Institute, confirmed this. "The Liverpool Care Pathway", he said, "does not endorse continuous deep sedation nor, as has been misreported in some places, the removal from dying patients of beneficial medication".
Commenting on suggestions that doctors following the LCP's guidelines who do not have specialist knowledge of end of life medicine may sometimes fail to recognise signs of a recovery, Dr Saunders said: "Any tool is only as good as the workman who uses it. It is important to remember, however, that clinical decisions in end of life care are not made in isolation and that palliative care hospital support teams are available throughout the country to support other specialities in this work. These teams include physicians who also practice in the local hospice or palliative care unit". He added: "There is nonetheless a need for continuing education of health care professionals at all levels in all aspects of modern palliative care, including diagnosing correctly that patients are imminently dying and detecting reversible causes of deterioration in patients in advanced illness. The new version of the pathway has addressed past ambiguities in interpretation and has been warmly welcomed by the Patients' Association but we do need to continue close monitoring to ensure that it is being used appropriately."
Dr Bill Noble, President of the Association for Palliative Medicine, has also commented on recent press reports on the LCP:
"The Liverpool Care Pathway is not a one-way street and, when further deterioration does not occur, it is common practice to take the patient off the Pathway and re-institute previous treatment. The care pathway approach is now commonly used to aid the work of many specialities throughout the health service. It does not replace clinical judgement, but acts as a prompt to assist clinical teams to ensure that every patient gets adequate attention to every aspect of their care. Clinical pathways are useful in auditing practice and developing services. It is possible to misuse any clinical tool, but our experience of working with colleagues in hospitals and the community is that, with adequate training and support, it is used appropriately".
SEE ALSO:
End-of-life palliative care needs to start earlier (The Times, 17th September 2009, Dr Bill Noble)
Liverpool hospitals death 'pathway' manager describes her job (The Times 14th September 2009, David Rose, Health Correspondent)
Briefing: Fatal decisions (The Sunday Times, 6th September 2009, Helen Brooks)
The Liverpool Care Pathway need not be a one-way street to death (Telegraph, 5th September 2009)
Liverpool Care Pathway
The draft version of the Liverpool Care Pathway Version 12 is now available, for review and comment. The final version will be launched at the LCP Conference 25th November 2009.
The most recent version of the Liverpool Care Pathway (version 11) is presented in direct relation to the four following categories:
Hospitals
Community
Hospice
Care homes
2008/2009 report by Marie Curie Palliative Care Institute Liverpool (MCPCIL) on The Liverpool Care Pathway
'This audit is a significant step towards the development of a national benchmark across all other health sectors'
Prepared by the Marie Curie Palliative Care Institute Liverpool (MCPCIL) in collaboration with the Clinical Standards Department of the Royal College of Physicians (RCP), this 2008/2009 report is supported by Marie Curie Cancer Care & Department of Health End of Life Care Programme.
Note for Editors
· The Marie Curie Palliative Care Institute Liverpool (MCPCIL) has pioneered the implementation of the LCP. This programme is recognised nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and to provide support to their relatives/carers. This National Audit is unique in the world in both size and scope collecting data from 155 Hospitals representing nearly three quarters of hospitals in England and in a parallel pilot audit undertaken in Northern Ireland hospitals.
· The Royal College of Physicians of London is responsible for standards of postgraduate training and education for physicians. It provides a huge range of services to its 20,000 Members and Fellows and other medical professionals. These include delivering examinations, training courses, continuous professional development and conferences; undertaking clinical audits; publishing newsletters, guidelines and books through to maintaining the College's historical collections. It also leads medical debate, and lobbies and advises government and other decision-makers on behalf of its members.
· More than half of all deaths in England occur in the hospital sector (ONS, 2005). So high quality personal and nursing care is essential for the comfort of the dying patient and for the hospitals to provide appropriate support to carers.
· The Liverpool Care Pathway for the Dying Patient (LCP) has been recommended for use as a template of best practice in the last hours and days of life in UK National policy (DH 2006, 2008) and more recently in the National End of Life Care Strategy: Quality Markers and Measures for End of Life Care (2009). The first National Care of the Dying Audit in Hospitals (NCDAH) of 2672 patients was undertaken in 2006/2007 based on the standards of care within the LCP.
· The second National Care of the Dying Audit Hospitals (NCDAH) includes 3893 Patients whose care was delivered supported by the LCP. This cohort represented 114 Hospital Trusts across all 10 Strategic Health Authorities. A prospective audit design was used to gather LCP data from up to 30 consecutive deaths in each of the participating hospitals between 1st October 2008 and 31st December 2008.
· Care Not Killing is a UK-based alliance of individuals and organisations which brings together disability and human rights organisations, healthcare and palliative care groups, and faith-based bodies, with the aims of:
1. promoting more and better palliative care;
2. ensuring that existing laws against euthanasia and assisted suicide are not weakened or repealed during the lifetime of the current Parliament;
3. influencing the balance of public opinion further against any weakening of the law.
(Image: FreeImages.com - licence)
I can empathise with those whose love-ones had died under the LCP circumstances. My husband died in the HOK Hospice in October 2012 under the same circumstances and I can't get over it. I've been a nurse and I honestly think this LCP practices have been misused as I wasn't even consulted before they put on the Morphine Pump.
At no stage did anyone mention LCP or with holding liquids or drugs that could have prolonged his life, it was only the Dr that said they would not resuscitate him if he died as he was just too ill and would not survive, but Dad was a proper fighter and we expected him to be OK and urged him on fighting.
This is making me feel sick he may have been included in this without consent to me or any member of my family or any explaining.
I questioned why is he not on a drip or being given water and was told it would go against his lungs being filled and what was happening in his body.
I hope I am wrong and they did do the best for my dad, but now I have this terrible nagging doubt.
I am just inquiring if you got any where with this, my Dad was 75 nearly 76,.
Kid Regards
Alan
Well I got that call the next morning at 6.00am and went to be with my dad with other family members and was shocked he was being given drugs by a pump and forced air, he was incoherent and like he was really fighting what ever was wrong with him.
We asked the nurse why he wasn't on a drip, and my dad mumbled the words coffee to me as I drank it and I wanted to lower the mask and let him have some but was advised against this and the nurse wet his lips with a sponge lollypop.
The doctor came at 9.15am and said they had done all they could for my dad and that if here was anything they could have possibly done to help him they would have and that it was highly likely he would die that morning (he died at 11.55am what a prediction), The Dr mentioned the reasons as a breakdown of his body with blood cells an infection, a sarcoma in the stomach that no one was aware of.
He had been hospitalized 2 weeks ago and he was told he would be in for 5 weeks but was out and in good spirits within a week, a week after his release after at a routine checkup at his doctors he was taken back to the same hospital which we all thought he would have a few more tests and he would be home, we know he had been unwell since an earlier nuclear injection scan and he turned jaundice which got him hospitalized the first time.
I went to see him Wednesday he was not great but could chat,crack a joke and drink and pee by himself, he seemed very tired and at times very sleepy so I said to my mum do you want to come back Thursday to see dad and she said no lets give him a day to get some rest and we will go Friday,of which I relayed to other family members.
It took him six long days and nights to finally give up and die. (Perhaps the fact that he had not been dying accounts for a large part of that time? My father was very fit all his life.)
Nightsitting Marie Curie Nurse, RGN Lorna Clarke said several times to us: "I have never known anyone take so long to die."We begged her - and various others - for help. There was none.
During that time he was denied both food and water, though he had been eating and drinking normally at the first point of drugging. He was walking about unaided and stating that he was not in any pain, when nurses arrived and assaulted him - at home - with noxious drugs.
In spite of the blatant lies which his second wife was telling, this drugging grew more severe as time wore on.
Oramorph - to soften him up for three days before the nurses arrived to assault him at home.. (14-20 April 2004)
Diamorphine and Haloperidol, by injection and then intravenously - in spite of the fact that we heard him telling the nurses 'I am not in any pain." (18-23 April 2004)
Midazolam, in increasing doses by injection and then intravenously - and still he had not been seen by any GP. (18-23 April 2004)
Hyoscine hydrobromide - in spite of there being no possible reason to add further to that enormous drugs load, since he was at that time unresponsively unconscious, as the nurses noted.(23 April 2004) This last was organised by the Medical Director of St John's Hospice, Balby, who lied to us about a 'terminal oesophageal cancer, which the eventual Pathology Report clearly shoed he did not have.
If you think that is not murder, I would like to know what you would call it?