Friday 31 May 2013

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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