Quoting Clive Seale, professor of medical sociology at Bart's and the London School of Medicine and Dentistry, the BBC reports that "there are fears that CDS is being used inappropriately". According to Professor Seale, in the UK "the prevalence of continuous deep sedation until death" is very high indeed, "16.5% of all UK deaths" which is twice as high as in Belgium and the Netherlands.
The BBC report echoes concerns voiced last year by Dr Adrian Treloar in a letter to the British Medical Journal. Dr Adrian Treloar, a senior consultant and lecturer in old age psychiatry, wrote about the Liverpool Care Pathway and, particularly, "serious weaknesses in its design".
"The Liverpool care pathway (LCP) is the UK’s main clinical pathway of continuous deep sedation and is promoted for roll out across the NHS", he wrote.
The NHS claims that the Liverpool Care Pathway is "used to care for residents in the last days or hours of life once it is known they are dying". However, in his letter to the BMJ, Dr Treloar warned:
"The eligibility criteria do not ensure that only people who are about to die are allowed on to the pathway. They allow people who are thought to be dying, are bed bound, and are unable to take tablets on to the pathway. In chronic diseases such as dementia, dying can take years, but such patients may be eligible ... GPs often put patients on to such a pathway without palliative care advice ... "Quoting a previous study published by the British Medical Journal (Murray SA, Boyd K, Byock I. Continuous deep sedation in patients nearing death. BMJ 2008;336:781-2. [12 April.]), Dr Treloar reiterated the concern expressed in that study:
" ... that sedation is being used as an inexpensive alternative to assessment and specialist treatment."Dr Treloar continued:
"The LCP recommends sedatives and opiates for all patients on an 'as required' basis, even when they are not agitated, in pain, or distressed. An automatic pathway towards prescribing heavy sedatives incurs risks. Moreover, the LCP recommends setting up a syringe driver within four hours of a doctor’s order. This is laudable, if it is needed. But the pathway encourages the use of syringe drivers even when symptoms can be managed without them ... "Dr Treloar goes on to cite the research of Dr Judith Reitjens and others also writing in the British Medical Journal (Rietjens J, van Delden J, Onwuteaka-Philipsen B, Buiting H, van der Maas P, van der Heide A. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. BMJ 2008;336:810-3. [12 April.]):
"The pathway doesn’t mention the need for food and fluids. Reitjens et al show that withholding artificial nutrition and hydration is the norm. The LCP’s omission of prompts to reconsider nutrition and hydration may allow serious errors in the care of dying patients. It is not acceptable, as Murray et al suggest, that assessing nutrition and hydration are not part of the pathway.Last year in the British Medical Journal was not the first time Dr Treloar had spoken out about the nutrition and hydration of patients. His warnings about the Liverpool Care Pathway must be taken very seriously and the BBC's report yesterday highlights a much wider, more serious, problem being encountered throughout Britain.
"Sedation is right in some situations. But as Murray et al point out, the anticipated outcome of continuous deep sedation is death. We must learn from Reitjens et al’s observation that continuous deep sedation may replace euthanasia. If the methods and pathways that we use for continuous deep sedation in the UK are flawed, then patients will die as a result of inappropriate use. I hope that the LCP will be reviewed and modified."
SPUC’s Patients First Network receives calls from distressed relatives saying that their loved ones are not being fed properly. Patients First Network is a support group which promotes good medical care until natural death. Anyone concerned about a friend or relative can call the Patients First Network confidential telephone support service on 0800 1691719.
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