A week or two back the headlines shouted that nearly one in three of those dying in hospital were the victims of euthanasia on the quiet. And the culprit was the Liverpool Care Pathway (LCP) – a sinister routine designed to hasten the sick and old to an early death from over-drugging and refusal of nutrition and hydration, thus freeing up a bed for the next victim. Why go to Switzerland when you can have death free on the NHS?
So let’s just have a look.
It is broadly accepted that the best chance of a peaceful death is to be in a hospice or, failing that, nursing at home with the assistance of hospice outreach. Hospital deaths appear to be the least satisfactory because a hospital is geared to healing, and may not be in a position to provide the best care. A depressing recent survey by the Office of National Statistics confirms that this is perceived to be so (link below). The LCP was designed to help bring the care of the dying in any institution up to the standards of best hospice care.
The protocols are quite detailed. They cover the diagnosis agreed by the multidisciplinary team, the care plan to be followed, a regular check routine, the appropriate medical and nursing information, pain control, provision of spiritual care, communication with the patient and the patient’s family, and informing the GP (link below).
The LCP has been recommended by the Department of Health as the best model for care of the dying. It is audited regularly. This shows a broadly satisfactory but somewhat uneven picture (link to 2011/12 audit below).
The protocol observes the moral principle of double effect that evil may not be done in order that good should be achieved. So we must not shorten life in order to bring about what, from our point of view, we may see as a quicker and so happier death. By the same principle we can, for example, reduce a patient’s pain even though the treatment may incidentally risk shortening of life, provided that the two ends are proportionate.
The criticisms launched at the LCP are understandable. The prediction of death is always uncertain and, although the LCP can and should be reversed as soon as the patient shows the possibility of recovery, this will be difficult to detect in the case of, say, a sedated patient. So the protocol requires a careful investigation of all the possibilities beforehand.
There is also concern about the withdrawal of nutrition and hydration. Surely, it is argued, these are natural needs and to withdraw them would be tantamount to taking life. But, surprisingly to us lay folk, at the last stages of life the system is closing down – and this withdrawal avoids imposing an increasing burden. But withdrawal should be the last resort (Royal College of Physicians, 2010).
The quoted figure that 29 per cent of hospital deaths have occurred to patients on the LCP has been interpreted by some as evidence that all these patients have been deliberately hastened to early deaths. But where the LCP has been conscientiously followed this would not be the case; it is gratuitous to claim otherwise. I have seen no credible estimate of the percentage of cases in which the LCP has been abused. I am happy to quote from Fr James Mulligan’s article in this paper in April 2010: “My own experiences of the LCP, from the perspective of hospital chaplain, have been very positive. I have certainly not found the heartless, box-ticking approach allegation to have any foundation. In fact, the opposite. I have been very impressed with how each patient is accorded dignity as an individual and how much the LCP carers strive to look after often the most idiosyncratic of needs.”
It would be naïve to suppose that abuses, perhaps amounting to euthanasia, do not occur – even if we cannot document them or be sure of the scale. Inevitably some medical staff will genuinely believe that a patient would be better served by accelerating his end. Others will allow the pressures of medical demands to distract them from the protocols. For example, a doctor might take a decision on his own without consulting the rest of the team or checks on patient who is on the Pathway might be too cursory to be reliable. Nor do I discount the possibility that the temptation to clear a much-needed bed will influence, perhaps subconsciously, the decisions made. It is certainly enough of a danger to be wary.
The best strategy for the next of kin, or the patient, if capable, is to be curious. You should show a lively interest about what is happening and intended, and state clearly that you would like to be informed before a decision is made. Ask questions. Medical staff who are proud of their care for the dying will be very willing to explain the reasons for their proposed decision, and to tell you how they will check for signs of recovery. I would ask to see the hospital protocol forms because it would give me a basis for questions (link to an example below). While the responsibility for care, in accordance with the best interests of the patient, remains with the doctor, you can always ask for a second opinion. And you should certainly do so if your questions have not been answered willingly, or you suspect that the protocol is not being followed correctly.
My thanks to Dr Trevor Stammers, programme director in bioethics and medical law at St Mary’s Twickenham, for his assistance. Any mistakes or misinterpretations are mine, not his.
LINKS (If you want to open the link in a new tab, copy and paste the link below into a new tab on your browser.)
Pocket guide to the LCP at
A recent survey of families’ experience of deathbed care. With charts. At
2011 – 12 audit of LCP by Marie Curie Palliative Care Institute and Royal College of Physicians. At http://www.mcpcil.org.uk/
A typical hospital group protocol for LCP, at