Saturday, 7 November 2009

Are they playing God?

This is the headline on the front page of the Romford Recorder, our most significant local newspaper. The sub-headline is: "Hospital stops food and medication for patients close to death".

The newspaper is reporting on a meeting of the local authority's Health Oversight and Scrutiny Committee. This committee is made up of local councillors who are not members of the local authority's Cabinet, and its role, with regard to matters of health, is as follows:

1. Providing a critical friend challenge to policy and decision makers.

2. Driving improvement in public services.

3. Holding key local partners to account.

4. Enabling the voice and concerns of the public.
The conception of oversight and scrutiny committees is somewhat similar, at the level of local government, to that of parliamentary committees that shadow departments at the level of national government.
One of the agenda items for the meeting of the Committee on 3rd November was the use of the Liverpool Care Pathway in the local NHS hospital trust. The Chair of the Committee, Cllr Ted Eden is quoted as saying:
Reports of the use of this pathway and its effects, including first-hand testimony I've heard, have been quite appalling. At precisely the moment [patients] need care, they are too often placed on what seems little more than a pathway to oblivion. In my view, this could easily be seen as playing God or even killing people off."
The representatives of the NHS hospital trust are reported as defending the Pathway as providing the best possible course of action for patients in terminal pain and agitation.
There is no hidden agenda. On the LCP patients die with dignity and with the best quality of life they have left.
There is nothing sinister about this - the LCP is not about shortening life. We do not believe in euthanasia, either passive or active, it's about excellence of care.
It is interesting that a web page which might be considered the "home" of the Liverpool Care Pathway includes the following sentence: "The use of the LCP does not preclude use of antibiotics or artificial nutrition or hydration but it does ask the professional to consider an appropriate decision for that moment in time and document the reason for decisions made."
But a set of sample documentation that I have been able to find for recording the patient assessment at the start of an implementation of the pathway has as Goal 3 the discontinuation of inappropriate interventions and lists blood test, antibiotics and intravenous fluids and medications as points to be considered under this heading. The wording clearly implies a presumption of discontinuation, and it views any "NO" to discontinuation as a variance from the pathway, to be recorded as a variance and justified, with a practitioner signature. No justification is expected for discontinuation, just a tick in a box. Goal 3a refers to discontinuation of inappropriate nursing interventions.
The LCP also expects anticipatory prescribing of drugs, ahead of the emergence of symptoms. This provision does seem, from the sample documentation, to include the administration of diamorphine in this anticipatory way.
[There are some good goals indicated in the documentation, an example being those related to spiritual and pastoral care of the patient and their family/friends.]

What we can see here, though, is an interesting use of local democracy to challenge the practice of the local NHS hospital trust.

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