End of Life and the LCP again: “I was thirsty, and you gave Me no drink” -Updated

Our mum is now in her final days of life after a fall the week before Christmas; a fall which either preceded or was followed by a subarachnoid tear and haemorrhage. For nearly three weeks mum has been cared for in an NHS hospital, but the Lord has blest mum and us in that we have been able to have her admitted into a care home run by a Catholic religious order. There the love and support of both mum and the family is proving to be second to none. As can be imagined, mum's end-of-life situation brought up for the family -again- the use of the infamous Liverpool Care Pathway (LCP). We asked from the time had mum her fall and was lying in an NHS hospital that the LCP not be used. This request has been readily agreed in the Religious House, where the consultation of the family and cooperation with our needs has been excellent. (I wish I could name the Order but I have not sought their permission).

Some physicians and nurses do seem to find it difficult to understand this objection to the LCP since, as one nurse said, “It is only used in the last 72 hours of life” (but who knows when those 72 hours begin? “Only God knows the day or the hour”). I was reminded by another nurse that “There’s a principle of Double-Effect you know; it’s OK to give Morphine even though it shortens life because it’s not given to do that; only to relieve pain.” The Principle of Double-Effect is a concept from Moral Theology with which I am very well acquainted and use frequently in Confession, which is why the family and mum's religious care staff have supported and encouraged the use of Midazolam even though it too depresses respiration: we are using it to relieve mum’s intense anxiety, not to depress her respiration. At any rate, in that mum has no physical condition which causes pain (no cancer; no fracture, no obvious cerebral irritation indicating headache) opiates (morphine and its derivatives) are not clinically indicated. Still, I think we could be a headache for physicians and nurses by requiring that fluids be given! As it is, mum's religious care-givers and the family are giving fluids to mum by subcutaneous infusion at a rate of 500mls per 24 hours. The reason for this is simple...

The average adult body holds a great deal of water. Around 28 litres of water is held within the body’s cells (intracellular fluid), and around 14 litres in extracellular fluid (3 Litres in the blood plasma; 1 Litre collectively in the cerebrospinal fluid, eye, peritoneal and synovial fluid, and 10 litres in the lymph and the water surrounding the body cells.) We maintain these fluid levels by drinking (principally) and by eating.  We lose it overtly in urine, faeces and vomitus. However, we also lose fluid by insensible (unseen) means at around 400-800mls per day (authorities differ). This loss occurs in our breathing and perspiration, and why in the movies you often see a mirror held to someone’s mouth to see if it mists up: they are looking for water vapour via breathing to see if the person is still alive. So if we as a family are requesting that mum receive 500mls of fluid per day, we are only asking that her insensible loss be replaced in order that a state of hydration be maintained; it is not possible to put her into fluid overload by simply replacing insensible loss. One of the medics with whom I spoke about mum's condition and care described the administration of fluid to me as “a life-extending measure”; I had to correct this and say “life sustaining”, in that it prevents death from dehydration, thereby sustaining mum’s comfort until the point of natural death; it cannot extend her life beyond that point. The term “life-extending” is very deceptive; it suggests death is being prevented, which is simply not possible with replacement of insensible fluid loss.

Mum’s fluids were at first given at a rate of 1 Litre per 24 hours, but then she passed no urine for 36 hours. Since output was therefore severely down and the infusion rate quite high by comparison we could have overloaded mum, so the family and staff have agreed to stop the infusion for 24 hours, recommencing it at the 500mls per day needed to replace insensible loss and avoid dehydrating mum to death; in truth, a form of passive euthanasia (euthanasia by omission).

Thank God we found a Catholic institution where the physicians and nurses are willing to work with us rather than against us in end-of-life care for our mother, herself a devout Catholic. We could well have been left with an institution which forces or seeks to ‘persuade’ (pressure) us to dehydrate mum to death by removing all fluid simply because a Care Pathway indicates that this is the way forward...

Removal of fluids was expressed this way by Andrew who visited mum yesterday: “I was thirsty, and you gave Me no drink...”  -and who wants to be the one who refuses to give Our Lord fluid when He is on His Cross..?  

UPDATE; Mum died peacefully, fortified by the Rites of Holy Mother Church, at 13.55 on January 14; the birthday of her eldest son, my eldest brother, who himself died a few short years ago...prayers please. Her Requiem will be celebrated on Thursday 24th of January at 10am, in her local parish Church.