Tuesday, 23 July 2013

The End of the Liverpool Care Pathway?

 The Liverpool Care Pathway (LCP) is to be phased out in the next 12 months and I am exceedingly pleased. 

When my mum was ill with pneumonia following a subarachnoid haemorrhage (neither of which need be fatal) physicians and nursing staff wanted to use the LCP. That was something I could not accept and so, at my request, mum was given subcutaneous fluids at a rate of 500-750mls per 24 hours (500 being roughly the amount of fluid one loses in exhaled breath over 24 hours, to say nothing of what one loses in sweat and urination). Some sedation was given to control mums agitation and anxiety, but no morphine (she did not give any indication that she was in physical pain). I believe she thus had a very peaceful and natural death, supported by excellent care from her attending nurses and physicians. I do not think this would have been the case if mum had been formally placed on the LCP which dehydrates the person and sedates them to the point that they are not aware of their dehydration; even if they were, they cannot voice it. It all looks very peaceful, but it remains an encouraged death in a sedated patient.

The intention of the LCP was good: helping hospitals to give as a good a care package to the dying and their loved ones that hospices can give, but its application is fraught with difficulty. The common criticisms recounted are that it was not always those formed to use it well who employed it; that there was a lack of consultation with relatives; that it was used to clear beds or to obtain financial reward. However, these are only attendant criticisms which fail to draw attention to the fact that in several ways, the Pathway itself is intrinsically flawed:

  1. It is a self-fulfilling prophecy since the removal of fluids or the failure to supply hydration assists in the inducement of death
  2. The administration of sedatives and opioid analgesics brings about respiratory insufficiency and the possibility of secondary infection
  3. A mistaken notion of ‘a peaceful death’ can only be assumed since the sedated patient cannot voice his/her distress.
  4. No one can know when death will occur in order that 72 hours before hand one can commence the LCP (A friend of mine said this flaw “has staff saying ‘We think she’ll be dead by Friday morning so let’s put her on the LCP’, which is not far from ‘Let’s put her on the LCP; she’ll be dead by Friday Morning’ ”.
  5. Provision for stopping the LCP after it has been initiated shows that its designers/users were aware that a diagnosis of impending death can be fatally wrong
  6. It presumes the difference between hospital and hospice care is one of medication and/or treatment, rather than one of setting and time/support given to patients and their loved ones. Acute hospitals do not have the same nurse/patient ratio as do hospices, and far fewer volunteers.

I will then, be glad to see the end of the LCP. My concern is that it has become so ingrained in staff over the last twenty years that it will continue to be practiced without the title; after all, our current medical and nursing staff are already formed by the LCP and influenced by  contemporary culture which say,s “we wouldn’t let a dog suffer that way; why should mum?” –this is a central argument put forward for euthanasia. When that argument is used to justify the LCP, both the LCP and euthanasia violate the primary principle of care: “First Do No Harm”.

In the early 1980’s I trained as a Nurse and there was no such thing as the LCP. Our hospital patients (including cancer patients) were given sufficient analgesia to keep them pain free, comfortable and conscious, achieved by increasing the dosage of morphine without simply doubling the dosage (though I did see this done). Pain charts monitored the patient’s pain level. Antibiotics were not given, and all unnecessary medications were discontinued. When even sips of fluids were difficult to swallow, patients were kept hydrated either by subcutaneous or intravenous infusion, and frequent mouth care was given.  Hygiene was either a bed-bath or hand and face wash as appropriate to the patient’s comfort; bedding was changed only when necessary. Positional changes were given prudently and only until such time as signs of impending death were noted (i.e., pulse and respiration changes, peripheral cyanosis etc) and airflow beds used to aid comfort and prevent pressure sores.  Thus there was no need for the LCP in my time, and I do not think there is need for it now.

I must have worked with physicians who were astutely careful in their use of opiates and sedatives, and nurses who did not mind how long they spent with a patient or their careful assessment of needs, because I never saw a patient experience a painful or distressing death in my time as a Nursing Auxiliary, Nursing Student or Registered Nurse. In all that time there was never a thought of removing fluids as done in the LCP. I did occasionally see opiates simply doubled when pain relief seemed inadequate, but on asking physicians to try intermediate dosages of analgesia and sedatives, pain relief without undue sedation was successfully achieved.

As noted in (6) above, where hospitals and hospices differ in the care they can give to the dying is not so much in their use of medication as in the comfortable nature of the setting; the time the nurses can spend with the patient, and the time, hospitality and support they can offer to the patient’s loved ones. These are things the LCP did not and could not address.  

At the risk of sounding repetitive, there was no need for the LCP in my time, nor should there be now. Good nurses never needed it before; they shouldn't need it now.

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