Liverpool Care Pathway: 1st pro-life group to sound alarm welcomes review's recommendation

The first pro-life group to sound the alarm about the Liverpool Care Pathway (LCP) has welcomed a report's recommendation that the LCP be replaced.

SPUC Pro-Life warned about the LCP as long ago as September 2008, in an article ("Liverpool Care Pathway – comfort for the dying or backdoor euthanasia?") in our newspaper The Pro-Life Times.

The Council of SPUC Pro-Life, our democratically-elected governing body of grassroots activists, passed the following motion yesterday:

"This Council:

• welcomes the call by Baroness Neuberger's review panel for the Liverpool Care Pathway to be phased out;
• salutes those relatives who have struggled to protect patients on the LCP;
• thanks all health care staff responsible for raising concerns about the LCP in public;
• congratulates the Pro-Life Times for raising concerns about the LCP in 2008;
• welcomes any proposal to prioritise ethical individualised care, which should include patient assessment by competent individuals and which should avoid not only over-burdensome treatment, but should also avoid over-sedation, neglect and the wrongful withdrawal of nutrition and hydration; and
• urges the Executive Committee to maintain its vigilance to identify and resist approaches which entail or lend themselves to euthanasia or assisted suicide."

Anthony McCarthy of SPUC Pro-Life told the media:

"SPUC welcomes the recognition, by an independent review, that the Liverpool Care Pathway is "the wrong approach" to end-of-life care and that it "should be replaced over the next six to 12 months.

"SPUC Pro-Life has supported consistently those medics who have criticised vocally the LCP. We will be closely examining any new proposals that may be put forward following the review. SPUC Pro-Life will be doing so with caution and in the knowledge that we live in an increasingly euthanasiast culture."

The LCP's implementation was draconian, with brave consultants such as Professor Patrick Pullicino threatened for highlighting the deaths that it can cause. Brave medics, families of victims and enterprising journalists have been at the forefront of exposing this structurally deficient pathway, often receiving little support from establishment figures who disagreed on its dangers.

SPUC is opposed to the giving of burdensome treatment to patients for whom it is no longer appropriate. We are also opposed to neglect of any patient. We want to protect the lives and welfare of vulnerable people by giving them what they need, when they need it, knowing that life has value at every stage.

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Professor Jones's LCP submission is a matter of great concern

Prof. David Jones (left) with Abp. Vincent Nichols

Professor David Albert Jones, director of the Anscombe Centre for Bioethics, is reported by The Tablet (16 May 2013) to be offering the reassuring news that his preliminary investigation into the Liverpool Care Pathway (LCP) finds that it:

“has not yet been demonstrated that the LCP is 'structurally unsound' or 'inherently unethical'.”

However, Professor Jones's reassurance (which appears in his submission to an enquiry, chaired by Baroness Julia Neuberger) merits, I believe, serious criticism - particularly since his submission could be presented as being on behalf of the Catholic Bishops’ Conference of England and Wales. His submission is headed Submission to the Review of the Liverpool Care Pathway [LCP] on behalf of the Department of Christian Responsibility and Citizenship of the Catholic Bishops’ Conference of England and Wales. In a footnote Professor Jones adds:

"This submission was prepared in an individual capacity at the request of the Department of Christian Responsibility and Citizenship of the Catholic Bishops' Conference of England and Wales".

Firstly, it seems to be nowhere mentioned in his submission that Professor Jones has been intimately involved in the ongoing formulation and promotion of the Liverpool Care Pathway, not only sitting on the National Reference Group of the LCP (see his Anscombe biography or the LCP Reference Group itself) but also giving talks promoting the LCP, at least once with the founder of the Pathway, Professor Ellershaw. Does this not represent a conflict of interests which could be embarrassing for the Catholic bishops of England and Wales?

Secondly, I ask the question: were all the bishops of England and Wales consulted about this submission, over which there is growing concern, not least from senior Catholic doctors? In this connection, I have been informed by one such doctor that none of the senior Catholic medics who are opposed to (or highly critical of) the LCP itself, as well as its implementation, were consulted by Professor Jones when making his submission on behalf of the Catholic bishops.

Thirdly, Professor Jones’s submission suffers from a number of defects. Having failed to mention the role of financial incentives in the implementation of the Pathway in his (recently revised) Comment on the LCP (posted "with the approval of the governors of the Anscombe Bioethics Centre" on the Centre's website), Professor Jones now acknowledges there is a problem. However, he does so in order apparently to minimise it, merely asking:

“Is there evidence (from minutes of meetings, emails, witnessed conversations etc.) that commissioners, managers or doctors believe that the LCP hastens death and saves money for that reason?”

... As if evidence for such could easily be found (the financial incentives were unmentioned by Professor Jones and by the key promoters of the LCP until a determined journalist at the Daily Telegraph made some Freedom of Information requests)... As if financial incentives don’t corrupt in multiform and latent ways, especially in end-of-life care in a country such as the UK. We do know, however, that in certain areas, targets have been set* specifically to increase the numbers of people in their hospital dying on the Pathway. Nothing of this appears in Professor Jones’s submission on behalf of the Catholic bishops of England and Wales. (*A lethal power? New Law Journal 23rd November 2012 Dr Jacqueline Laing, BA, LLB (ANU) DPhil (Oxon), barrister, High Court of Australia, senior lecturer in law, London Metropolitan University.)

Fourthly, Professor Jones tells us all disagreements about the LCP are 'empirical', yet he has neither medical qualifications nor expertise in the analysis of empirical data. On the crucial issue of diagnosis of impending death he quotes and gives central importance to an unblinded study in which the raters were also the carers. Indeed, the LCP is predicated on prognosis yet there is no reliable scientific evidence to show that it is possible to predict reliably the timing of death within a period of hours or days. As Professor Pullicino, pointed out in his lecture to the Royal Society of Medicine (June 2012) Can we predict impending death? The scientific evidence:

“The LCP does not attempt to use any published prognostication index to determine who goes onto it” and that 'being within the last hours of days of life' is really a prediction not a prognostication.” 

There is no recognition that the LCP is not evidence-based, as judged by authoritative Cochrane Reviews.

Fifthly, the submission dismisses cavalierly the media coverage which seeks to give voice to the huge number of complaints about the Pathway. Here Professor Jones reveals the partial nature of the submission. He focuses attention on a tiny number of sloppy articles (as there inevitably are for any news story) amidst a mini-mountain of witness statements and evidence regarding the flaws in the LCP and its implementation. Incredibly, no mention is made of the many misleading statements made by supporters of the LCP.

Sixthly, as Professor Pullicino, Dr Philip Howard and Dr Anthony Cole have noted:

“He supports the idea of withdrawal of fluid and sedative management in "dying" patients, without showing he understands how this conflicts with the physiology of thirst and the respiratory and central nervous system depressant effects of opiates and benzodiazepines”.

They add:

"He fails to highlight the pivotal place of the diagnosis that a patient is 'dying' in the LCP. He accepts the term 'dying patient' with only superficial discussion. He mentions that if the diagnosis of 'dying' is wrong, then reduction of fluids could be fatal. He does not see the potential for this to bring about a 'self-fulfilling prophecy' in someone diagnosed as 'dying' in the LCP, although he says that there is some concern for those 'who live longer than expected'.

"He is very critical of the views of Catholic physicians who have reported on the LCP and fails to do justice to what they put forward.”

It seems to me to be a matter of great concern that an individual's partial views should form an official response by the Catholic bishops. It will now appear that the official Catholic line on the LCP is one of support, together with a dismissive attitude toward critics.

We do not need an evangelist for the LCP. We need submissions which deal objectively with the scientific and ethical issues.

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Act to stop Liverpool Care Pathway being used as "backdoor euthanasia"

My colleague, Paul Tully, SPUC's general secretary, has issued the following stark appeal this afternoon concerning the Liverpool Care Pathway.

Please Act Now to stop the Liverpool Care Pathway being used as 

“backdoor euthanasia” for NHS patients

A number of families have spoken out in the media about the abuses their loved ones have suffered as a result of being put on the Liverpool Care Pathway in hospitals and nursing homes.

Several senior doctors have publicly criticised the use of the Pathway, asserting that it can mean hastening death for vulnerable patients. Patients are dying as a result of the Pathway – not simply from their underlying conditions.

In the face of these criticisms, the government asked Baroness Julia Neuberger to chair a “review” panel. The panel is receiving submissions (letters, emails, etc) from anyone with concerns about the Liverpool Care Pathway. Anyone can make a submission, but the experience of those who have been affected is particularly important (such as patients or relatives, healthcare staff, chaplains, visitors, etc).

The deadline for submissions is Friday, 5 April 2013.

Send submissions to:
Liverpool Care Pathway Review
Department of Health
Richmond House
79 Whitehall
London SW1A 2NS

or by email to:
liverpoolcarepathwayreview@dh.gsi.gov.uk

The review panel has not issued a questionnaire or pro-forma for submissions, so you can write to them in any format you wish, but we give some suggestions below about how to set out your concerns.

The composition of the Neuberger review panel includes leading pro-euthanasia advocates – David Aaronovitch and Professor Emily Jackson; and Baroness Neuberger herself has said (in the annual Tyburn lecture in 2011) that she had “ ... some sympathy with the idea that that people who are already terminally ill and finding their situation unbearable, that they should be given the wherewithal to take their own lives ... ”

It is important that they receive clear statements defending vulnerable people (especially the elderly) from attack, whether by medical abuses or by having the law amended or ignored so that vulnerable people can have their lives deliberately shortened by act or by omission. Please point out that the review panel has no brief to recommend weakening legal protection for the lives of patients.

Contact me at johnsmeaton@spuc.org.uk for SPUC's briefing on preparing a submission for the Liverpool Care Pathway Review.

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"Has Liverpool Care Pathway become a licence to kill?" asks professor in care of the elderly

Severe criticism of the Liverpool Care Pathway from Professor Brian Livesley, an emeritus professor in the care of the elderly in London, has appeared in the British Journal of Healthcare Management.

Under the headline: "Has care pathway turned into a licence to kill difficult patients", today's Daily Telegraph reports:

The Liverpool Care Pathway appears to have become a "licence to kill” through misuse by doctors and nurses, a leading palliative care expert has said.

Starving and dehydrating someone to death may have become a way of dealing with a “problem patient” because modern health care professionals do not know what else to do, Prof Brian Livesley warned.

The emeritus professor in the care of the elderly at Imperial College School of Medicine, London, warned that limited experience of dying patients because of the lack of life threatening epidemics had created “inadequacy among doctors and nurses".

Writing in the British journal of Healthcare Management, he asked if this had allowed “a pseudo-form of the Liverpool Care Pathway to be used to remove the ‘problem patient’ under a ‘starvation and dehydration quick-fix’”.

He added: “By misuse has the Liverpool Care Pathway become a licence to kill?”

Prof Livesley said the guidelines should mean that symptoms such as thirst, pain and hunger were dealt with while unecessary treatments were avoided. “After all for conscious patients particularly, starvation and dehydration are terrible ways to die,” he wrote.

“Inducing death by neglect when a person has unrelieved symptoms also exposes wilful and/or negligent clinical staff - as well as their administrators - to the certain risk of criminal charges.”

The pathway, a set of guidelines aimed at providing hospice standard care of the dying in hospital, has become controversial after high profile cases of patients being denied food and water in their final days. Some have said that it is akin to euthanasia.

A Department of Health spokesman said: “Experts agree the Liverpool Care Pathway can play a vital role in making sure a person’s final hours are as pain free and digniied as possible.

“However, we have seen that there are too many cases where patients or their families have not been properly involved in decisions.

“This is unacceptable. That is why Baroness Julia Neuberger has been appointed to chair an independent review"

The Department of Health spokesman completely misses the professor's point. Health professionals cannot mitigate the crime of inducing death by starvation and dehydration by seeking to involve patients and/or their families in such neglect. It's no wonder that concern about the Liverpool Care Pathway continues to grow when a department of health spokesman makes such an astonishing comment.

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The appointment of Julia Neuberger to head Liverpool Care Pathway inquiry is worrying

The Government has just announced that Baroness Julia Neuberger, a rabbi and former Liberal Democrat health spokesperson, has been appointed to chair the government's inquiry into the Liverpool Care Pathway (LCP) (see my blog last week on the LCP). This appointment is worrying. In 2011 she said in the annual Tyburn Lecture (my emphasis in bold):

“Just so everyone knows, let’s be very clear, I am not in favour of euthanasia, I am not in favour of physician-assisted suicide. I don’t think it is a good idea for our health professionals to kill their patients any more than they do accidentally, I just don’t think it is a good idea.

I do have some sympathy – and many people I think will disagree with me – I do have some sympathy with the idea that that people who are already terminally ill and finding their situation unbearable, that they should be given the wherewithal to take their own lives. I am sure that many people – those who are true Catholics will strongly disapprove of that and there are Jews who strongly disapprove of that – but I do have some sympathy because there are some people for whom actually life becomes unbearable when they can’t control the pain. I think it is the exception. All the experience where that has been tried, for instance, in Washington State in the United States has shown that when people are given the wherewithal they barely ever use it, which suggests they want the reassurance rather than the actual capacity to deal with it.”

But there are few ethical differences between euthanasia and physician-assisted suicide (which she claims to oppose) and suicide assisted by non-physicians (for which she expresses sympathy). In all those three categories, the intentional killing of an innocent member of the human family is brought about.

And in 2005 she voted against an anti-euthanasia amendment to the pro-euthanasia Mental Capacity Bill (now Act). The amendment would have removed the ability of attorneys to deny life-sustaining treatment to mentally-incapacitated patients.

One of the most worrying claims about the nature and operation of the Liverpool Care Pathway (LCP) relates to euthanasia by omission (sometimes called euthanasia by neglect) - the  denial of life-sustaining care (food and/or fluids) and/or reasonable medical treatment. Her vote against the amendment should disqualify her from the chairmanship of any inquiry into the LCP.

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