NHS Pathways to Death

NHS Pathways to Death: is it State Sanctioned Murder?

NHS Pathways to death seems to be aimed at hastening death in order to cut NHS bills.

Most families will be defenceless against these tactics, which seem more reminiscent of those employed by the Nazis on the 1930’s and 1940s.   In effect, hospitals are being paid more to hasten the death of terminally ill patients.

Hospitals are supposed to discuss the withdrawal of food, fluid and treatments with patients where possible, and with families.  However, this does not always appear to be happening and some families are totally unaware that their loved ones are on the NHS Pathway to Death.   Not that families have any right whatever in these circumstances unless there is a registered Lasting Power of Attorney Health and Welfare in place.  Sadly, these take 3 months to create and register, so the only way a family can fight the Health Authority is by getting a Court Order from the Court of Protection at considerable cost – if you can get it in time.

In some areas around 9 in 10 patients who die are on the NHS Pathway to Death: no one is pretending they are not going to die anyway, but a straightforward lethal injection would have to be preferable to slow starvation and dehydration. At least, that is my opinion.  Murder by neglect is just a slow way of achieving what an honest lethal injection would do in minutes – and save the NHS more money, and avoid a lingering death, which the NHS assume the patient will not be aware of.  And no one actually knows what is happening in the mind of the poor patient.   Hastening death may well be right, but doctors should not be bribed to finish off patients early just to cut NHS costs.

Doctors are not allowed to perform mercy killings for concious patients who are in agony, but they are paid to kill off the terminally ill by deliberate neglect.  It just doesn’t make sense.

We have two messaged for people:

  1. Arm yourselves with Welfare Lasting Powers of Attorney so your loved ones stay in charge, and have authority to fight the NHS Pathways to Death if necessary.
  2. Ask your MP to start a proper debate about euthanasia, which is illegal unless you are a doctor being (indirectly) bribed to put people on the NHS Pathways to death to cut NHS costs.

NHS Pathway to death.

10 thoughts on “NHS Pathways to Death

  1. Lasting Power of Attorney Post author

    Liverpool Care Pathway: response to media reporting

    Negative stories about the Liverpool Care Pathway have led some health professionals to call the National End of Life Care Programme with concerns about the impact on staff morale and wider confidence in this valuable tool.

    There is one over-arching message which the National End of Life Care Programme wants to emphasise to clinicians and to those with a relative who might be placed on the pathway: the LCP has improved and continues to improve care of the patient in the last days or hours of life. This is our unambiguous position.

    The LCP provides an evidence based framework for the delivery of appropriate care for dying patients and their relatives in a variety of care settings. Its use has recently been endorsed by Strategic Health Authority End of Life Care Clinical Leads at a meeting with Professor Mike Richards, National Clinical Director for Cancer and End of Life Care.

    The LCP must, however, be followed correctly. Training, skilled assessment and regular review of individual patients’ condition, effective communication with family members and participation in audit are all essential to the optimal use of LCP.
    Two national audits, the latest of which reported just last month (September), support the use of the LCP.

    In its press statement on the second audit, the Royal College of Physicians, which took
    part in the audit, said: “The audit results are as impressive as those of the first audit,
    published in 2007. This shows that standards of patient care remain high and underlines the value of the LCP in providing a framework in which clinical judgement can be exercised for the benefit of individual patients.”

    Addressing the issue of the use of sedatives, which has been questioned or criticised in the media, the Royal College examined the figures.

    Its verdict? “These findings indicate that dying patients receive good clinical care, tailored to the individual and their distress, when supported by the LCP….In the last 24 hours of life the vast majority of patients are reported to be comfortable.”

    The audits were the first of their type in the world. The second audit collected information from 155 NHS hospitals – nearly three-quarters of those in England.

    The pathway requires senior doctors and nurses involved in the patient’s care to agree that death is very likely to be imminent and that being placed on the pathway would reduce patient discomfort and pain.

    That decision should involve the patient, where possible, and certainly the family.
    Clinicians should explain why certain medication is being withdrawn and – in some cases
    – nutrition and fluid reduced if and when those decisions are taken.

    Ward staff should ensure that the patient is comfortable and their symptoms managed
    according to their individual needs.

    The patient must be re-assessed at least every four hours. Those re-assessments do, in around 3% of cases, lead to the patient being removed from the pathway. In one of the recent stories condemning the pathway’s use this is exactly what happened.

    Diagnosing dying has never been – and probably never will be – an exact science.
    We know that staff have to be trained and educated in the proper use of the pathway.
    Our own contacts with NHS trusts suggest that the importance of education and training in the use of the LCP and in wider end of life care issues is well recognised.

    Many Trusts already appear to have extensive programmes in place while others are
    planning to expand education and training. The national audit found, however, that only four in ten trusts have an LCP facilitator. We would like to see that figure increase
    significantly to ensure the expansion of LCP from its origins largely in cancer units to
    other parts of the hospital, so that staff on all relevant wards are properly trained and
    educated. The facilitator would ensure that latter condition was met. Advice and support should also be available from, specialist palliative care teams when necessary.

    The importance of prior and on-going communication with the family is emphasised by
    the recent media coverage. In several cases highlighted in the media, the patient was not even on the pathway – with some cases predating the adoption of the pathway.

    We know that some trusts are developing their own leaflet for patients and/or relatives to explain the LCP. A local leaflet can be useful but all trusts should ensure that the relatives leaflet written by the LCP Central Team at the Marie Curie Palliative Care Institute Liverpool is made available. Staff should talk to the family and allow them the time to absorb information from the leaflet and in the vast majority of cases there is a sad acceptance that the pathway offers their loved one the best prospect of a peaceful death.

    If you follow the pathway – and that includes talking to the family and regular checks on the patient – the LCP will help you and your colleagues as you seek to ensure dying patients die comfortable deaths.

    The institute’s leaflet and more information is available on its website at
    http://www.liv.ac.uk/mcpcil

    Professor Mike Richards
    National Clinical Director for Cancer and End of Life Care
    Claire Henry
    National Programme Director

    http://www.endoflifecareforadults.nhs.uk email: [email protected]

  2. Lasting Power of Attorney Post author

    I am told that dying of dehydration or starvation are two of the nastiest ways to die.
    No one really knows how much a terminally ill patient may suffer.

    And some people recover and walk away from the Pathway. So selection is far from an exact science, and whichever way you look at it, it’s EUTHANASIA! And that is illegal.

  3. Lasting Power of Attorney Post author

    Consensus Statement: Liverpool Care Pathway for the Dying Patient (LCP)

    Published misconceptions and often inaccurate information about the Liverpool Care
    Pathway risk detracting from the substantial benefits it can bring to people who are dying and to their families. In response to this we are publishing this consensus statement to provide clarity about what the Liverpool Care Pathway is – and what it is not.
    The hospice movement in the UK is famous around the world for looking after dying people with dignity and skill. Since the late 1990s, the Liverpool Care Pathway has been helping to spread elements of the hospice model of care into other healthcare settings, such as hospitals, care homes and people’s own homes.

    The Liverpool Care Pathway:
     Requires staff ensure all decisions to either continue or to stop a treatment are taken in the best interest of each patient. It is not always easy to tell whether someone is very close to death – a decision to consider using the Liverpool Care Pathway should
    always be made by the most senior doctor available, with help from all the other staff
    involved in a person’s care. It should be countersigned as soon as possible by the
    doctor responsible for the person’s care.
     Emphasises that people should be involved in decisions about their care if possible
    and that carers and families should always be included in the decision-making
    process. Of those who responded as part of the evaluation, 94% said that they had
    been involved (National Care of the Dying Audit – Hospitals, MCPCIL/RCP, 2011).
     Relies on staff being trained to have a thorough understanding of how to care for
    people who are in their last days or hours of life.
     Is continually evaluated in all the places where it is in use.
    The Liverpool Care Pathway does not:
     Replace clinical judgement and is not a treatment, but a framework for good practice.
     Hasten or delay death, but ensures that the right type of care is available for people
    in the last days or hours of life when all of the possible reversible causes for their
    condition have been considered.
     Preclude the use of clinically assisted nutrition or hydration – it prompts clinicians to
    consider whether it is needed and is in the person’s best interest. GMC guidance
    (2010) provides specific information regarding this issue.

    In response to a question asked in the House of Lords on 20th June 2012 the Parliamentary Under Secretary of State for Health, Earl Howe, said “The Liverpool Care Pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good.”

    The Liverpool Care Pathway has been suggested as a model of good practice in the last
    hours and days of life by successive national policy frameworks (DH, 2003 and 2006), the national End of Life Care Strategy (DH, 2008), Quality Markers and Measures for End of Life Care (DH, 2009), General Medical Council guidance (2010) and the NICE quality standard for end of life care for adults (2011).

    We support the appropriate use of the Liverpool Care Pathway and make clear that it is not in any way about ending life, but rather about supporting the delivery of excellent end of life care.

  4. Lasting Power of Attorney Post author

    Liverpool Care Pathway for the Dying Patient (LCP) ‐ FAQ

    What is the LCP?
    The Liverpool Care Pathway for the Dying Patient (LCP) is a model of care which enables healthcare professionals to focus on care in the last hours or days of life when a death is expected.  

    The LCP is tailored to the person’s individual needs and includes consideration of their
    physical, social, spiritual and psychological needs.  It requires senior clinical decision making, communication, a management plan and regular reassessment.  

    The LCP is not a treatment in itself but a framework for good practice – it aims to support, but does not replace, clinical judgement.    

    The LCP guides and enables healthcare professionals to focus on care in the last hours or days of life, when a death is expected.  However, communication, care and compassion must come from all the healthcare workers caring for an individual patient and their family.  
     
    Who is responsible for the development of the Liverpool Care Pathway?  
    The Marie Curie Palliative Care Institute Liverpool (MCPIL) has overseen the development and dissemination of the LCP.  Responsibility for day to day implementation of the LCP lies with individual hospitals, GPs and care homes.  Implementation must always be underpinned by a robust education and training programme. The LCP has been reviewed regularly and a 2 year consultation exercise led to the design of the LCP generic version 12.
    The use of the LCP in hospitals is audited by The National Care of the Dying Audit – Hospitals (NCDAH).  The most recent audit took place in 2011.

    Is the Liverpool Care Pathway a recommended model of care?

    The LCP is an integrated care pathway (ICP); ICPs are used throughout the healthcare system to ensure excellence in patient care (Ellershaw J. & Wilkinson S. 2011). It has been recognised nationally and internationally and recommended as a model of good practice to support care in the last hours or days of life by successive national policy frameworks (DH, 2003 and 2006), the National End of Life Care Strategy: Quality Markers and Measures for End of Life Care (DH 2009), General Medical Council (GMC) guidance (2010) and the NICE Quality Standard (2011).   

    When should the LCP be used?
    Recognising that someone is in the last few hours or days of life is always complex, it
    requires a multi‐disciplinary team approach and should be led by the most senior  doctor ultimately responsible for the patient’s care.  The LCP should be considered when there is no appropriate reversible treatment available and the team considers that the patient is in the last hours or days of life.
    Uncertainty is an integral part of dying. There are occasions when a patient who is thought to be dying lives longer than expected and vice versa.  This means that good communication and support for the patient, the relatives and carers is vital.   
    When it is determined that the patient is dying, all care and treatment must be reviewed; some interventions will be continued, some discontinued, and others started. A referral to the specialist palliative care service or a second opinion should be sought as appropriate.
    1Good, comprehensive, clear communication is essential and all decisions leading to a change in care delivery should be communicated to the patient where possible and deemed appropriate, but always to the relative or carer. This is in accordance with GMC best practice guidance (GMC 2010).  The views of all concerned must be listened to, considered and documented.

    Does the patient or relative need to give written consent to use the LCP?

    No, the LCP is not a treatment but a framework for good practice, therefore, written consent is not required. However,  identifying that someone is in the last hours or days of life and agreeing a plan to support care in the last hours or days of life should be discussed with the patient where possible and deemed appropriate and always with the relative or carer.

    How will a relative or carer know if the LCP is being used?   
    Acknowledging that a patient is dying and making the decision to use the LCP to support care in the last hours or days of life should be discussed by the clinical team, with the patient where it is possible and deemed appropriate and  always with the relative or carer, in accordance with GMC best practice guidance (GMC 2010).  All significant conversations should be supported by appropriate written information about the LCP.   

    Therefore there should never be an occasion when the relative or carer who is named as the first contact or next of kin is unaware of the diagnosis of dying or of the subsequent care plan.
       
    What happens if the relative or carers disagree with the use of the LCP?

    As with all clinical decisions in healthcare, the senior doctor and the multi‐disciplinary team should reach consensus about what care is appropriate at this time. If disagreements occur between the members of the healthcare team or between the healthcare team and those close to the patient, then the clinical team should involve an independent advocate, and/or should seek advice from another senior colleague, and should also seek a second opinion and/or use local mediation services. (GMC 2010)
    Good, comprehensive, clear communication is crucial and all decisions leading to a change in care delivery should be communicated to the patient where possible and deemed appropriate but always to the relative or carer. The views of all concerned must be listened to, considered and documented.

    (ED: this means that neither the patient for the next of kin have any authority whatver, which is frightening. Can doctors now ignore Lasting Powers of Attorney anbd Medical Directives – backed by the Law – with impunity?

    Does the LCP recommend continuous deep sedation?

    No, the LCP recommends a full review of all medication currently prescribed.  Medications for the most common symptoms including pain are prescribed, should they be required.  
    However, medicines for symptom control will only be given when needed in response to a symptom, at the right time and just enough and no more than is needed to help with the symptom.  

    National Care of the Dying Audit – Hospitals Round 2 Generic Report (2008/2009) reviewed the prescription and administration of medication for agitation and restlessness in the last 24 hours of life.  The results demonstrated that where medication was prescribed or administered the dosages and frequency of use were low and there was no evidence of continuous deep sedation.  (Gambles et all 2011)

    2Does the LCP recommend stopping or not commencing clinically assisted (artificial)
    nutrition or hydration?

    No, the LCP does not preclude the use of clinically assisted nutrition or hydration (CANH).  
    Indeed the LCP prompts clinicians to consider the need for CANH.  All clinical decisions must be made in the patient’s best interest and tailored to the patient’s individual needs.  The GMC guidance provides specific information regarding this issue.  (GMC 2010)
    Each patient is an individual with individual needs. Some patients will have a drip continued, some will have a drip discontinued or indeed commenced. These best interest clinical decisions should be made by the senior doctor ultimately responsible for the patient’s care at that moment in time supported by the multi‐disciplinary team, and reviewed regularly.
    All decisions leading to a change in care delivery should be communicated to the patient where possible and deemed appropriate but always to the relative or carer. The views of all concerned must be listened to, considered and documented and all significant conversations should be supported by an appropriate written information leaflet.

    Is the LCP a form of euthanasia?
    No, the LCP guides and enables healthcare professionals to focus on the best possible care in the last hours or days of life.  This includes consideration of the individual patient’s physical, social, spiritual and psychological needs.  This requires assessment, senior clinical decision making, communication, a management plan and regular reassessment.
    The LCP exists to support good decision making in the last hours or days of life which will focus on ensuring good quality of care. The provision or withdrawal of interventions with the direct aim of hastening death is contrary to the rationale of the LCP, contrary to GMC guidance, and illegal.
    The LCP aims to support, but does not replace, clinical judgement.  Clinical decision making is the responsibility of the clinical team looking after the patient. All decisions must be made in the patient’s best interest, tailored to their individual needs. The LCP is in accordance with the decision making processes as outlined in the GMC Guidance (2010).

    How often should the patient be reviewed when supported by the LCP?
    The patient should be reviewed as often as needed as each patient and their relatives and carers have individual needs.  However, irrespective of clinical need, the patient in an in‐patient unit (e.g. a hospital) should be reviewed at least 4 hourly, and at home each time the doctor or nurse visits.
    In addition to these regular 4 hourly assessments as outlined above, a full multi‐disciplinary team review of the plan of care should occur when:
     the patient appears to have an improved conscious level, functional ability, oral
    intake, mobility, or ability to perform self‐care
     concerns are expressed regarding the management plan by either the patient, the
    relative or carer or healthcare worker
                   or
     It is 3 days since the last full mult‐disciplinary assessment

    As above, this assessment and the subsequent outcome should be communicated to the patient where possible and deemed appropriate but always to the relative or carer.

    3What if the patient improves can the LCP be discontinued?

    Yes, the LCP can be discontinued following a review of the patient’s condition by the multi‐disciplinary team and in consultation with the patient, where possible and always with the relative or carer.  The views of all concerned must be listened to, considered and documented.  (GMC 2010)

    How is the LCP monitored?
    Any organisation that cares for dying people should be able to demonstrate best practice in care of the dying including the last hours or days of life.  End of Life Strategy (2008), GMC (2010), CQC (2010), NICE (2011).

    Each Organisation should ensure;
     it has an End of Life Strategy including the use of a best practice model for care in
    the last hours or days of life, which is monitored at executive board level;
     a named person is employed and responsible for driving up quality for care of the
    dying in the organisation;
     the Specialist Palliative Care Team offers a 7/7 face to face service with an out of
    hours support line;
     the organisation audits care of the dying against the best national benchmark; and
     all those who care for dying patients are trained to do so.
    The responsibility for use of the LCP lies with the organisation which is using it. It should be used as part of a continuous quality improvement programme within the governance of the organisation and it must be underpinned by a robust education and training programme.  

    The LCP, like any other end of life care tool, or an escalation of care tool, is itself the product of a review of good practice and is in place to enable the delivery of safe, standardised, effective patient‐related outcome measures. The monitoring and governance of any best practice tool or technology is the responsibility of the organisation using it.  

    Where can I find out more information?
    http://www.liv.ac.uk/mcpcil/liverpool‐care‐pathway/

    The LCP guides and enables healthcare professionals to focus on care in the last hours or days of life, when a death is expected. However, communication, care and compassion come from all the healthcare workers caring for an individual patient and their family.
    Care must be delivered, communicated and assessed within the organisational governance framework.

    This FAQ has been prepared by the National End of Life Programme, Marie Curie Cancer Care, and the Marie Curie Palliative Care Institute Liverpool.  
    45
    REFERENCES
    Care Quality Commission (CQC) (2010) Essential Standards of Quality and Safety. CQC.
    London.  Department of Health (2006) Our Health, Our Care, Our Say: a new direction for community services.  
    London, DOH
    Department of Health (2008) End of Life Care Strategy – promoting high quality care for all adults at the end of life.
    DH. London
    Department of Health (2009) End of life Care Strategy ‐ quality markers and measures for end of life care. DH. London
    Ellershaw J. & Wilkinson S. (2011) Care of the dying: a pathway to excellence. 2nd rev ed. Oxford: Oxford University Press.
    Gambles M., McGlinchey T., Latten R., Dickman A., Lowe D. & Ellershaw J.E. (2011) ‘How is agitation and restlessness managed in the last 24 hours of life in patients whose care is supported by the Liverpool Care Pathway for the Dying Patient’ BMJ Supportive and Palliative Care. 1 (3) pp. 329 – 333.
    General Medical Council (2010) Treatment and care towards the end of life: good practice in decision making – Guidance for doctors, via
    http://www.gmc‐uk.org/static/documents/content/End_of_life.pdf  
    National End of Life Care Programme (2010) The route to success in end of life care –
    achieving quality in acute hospitals, via
    http://www.endoflifecareforadults.nhs.uk/assets/downloads/rts_acute_hospitals.pdf
    National Institute for Clinical Excellence (2011) Quality Standards: End of life care for adults.
    Accessed via http://www.nice.org.uk/guidance/qualitystandards/endoflifecare/home.jsp  
    National Care of the Dying Audit ‐ Hospitals Round 2 Generic Report (2008/2009), via
    http://www.mcpcil.org.uk/pdfs/Generic_NCDAH_2nd_Round_Final_Report%5B1%5D.pdf
    National Care of the Dying Audit ‐ Hospitals Round 3 Generic Report (2011/2012),
    http://www.mcpcil.org.uk/media/livacuk/mcpcil/documents/NCDAH‐GENERIC‐REPORT‐2011‐2012‐FINAL.doc‐17.11.11.pdf
    Royal College of Physicians http://www.rcplondon.ac.uk/resources/clinical/audits   

  5. Thayna

    “None of us want to be thought of as uncaring or turning a blind eye.”there is nothing uncaring about what your post revealed. take your focus of thought off of those who are getting free health care when they can afford to pay and refocus your thoughts by thinking of how it affects those who are providing the care. they are people too. the government doesn’t force grocery stores to provide food, an essential need. the government doesn’t force clothing stores to provide clothing, an essential need. the government doesn’t force apartment owners to provide shelter, an essential need.but one thing more, each of these enterprises can freely choose to provide their wares and services if they so “choose.”and if “preventive medicine” is the philosophy of the day these are more important than medical care, itself.when you force people to provide for others you take away the “right of choice.” but, more important you take away the opportunity for that person to provide an act of charity.

  6. Sports injuries

    We’re a group of volunteers and opening a new scheme in our community. Your website offered us with valuable info to work on. You have performed an impressive task and our entire group will likely be grateful to you.

  7. concerned

    lets be honest the whistleblowers have put paid to the mass execution while on the liverpool care pathway or do they care, lets stop this l c p scam to save money and kill patients whilst doing this evil act anyone with any sense knows that to sedate them as well as starvation there is only one result death itsthe most barbarick treatment ever to be sanctioned by britain how in gods name its been allowed to go on for so long talk about a well kept secret it has been done very sly behind peoples back, i think thats why it is called back door euthanasia, wake up english citizens and stop these killings.

  8. concerned

    lets face it doctors and nurses are now opening up sites saying i like the lcp trying to get back at patients relatives who are complaining about the euthanasia inflicted who have had a loved one starved and dehydrated to death and not forgetting the morphine syringe drivers, its a guilty feeling and will be looked at for years to come about its wrongdoing and mass murders yes murders and it cannot be denied when you have professors and doctors in this field of work condeming it as barbaric, the facts are there to be seen god help england its going down the drain all for what saving money and killing to do it.

  9. Lasting Power of Attorney Post author

    Extract from an interesting article on the NHS Pathways to Death – you can read the whole article here: http://www.lawgazette.co.uk/opinion/managerialising-death?utm_source=emailhosts&utm_medium=email&utm_campaign=GAZ+06%2F02%2F2013

    The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago.The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago.

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