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Medical Ethics Alliance

Talk for House of Lords Meeting 23rd January 1013

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I would like to thank Baroness Knight for arranging this meeting and for the opportunity to say a few words about the Liverpool Care Pathway which is said to be used in 80,000 deaths a year.

Conscious of entering the autumn of my life, the manner of leaving  it comes more readily  to mind, not least because of the recent controversy.

Since the pioneering work of Dame Cecily Saunders there is no need to fear unrelieved pain, but what I do fear is thirst. In a letter to the Chief Executive of NICE ( National Institute of Clinical Excellence ) I asked;

“How long  should a person be without fluids”?

No answer was forthcoming from him nor subsequently from the Association of Palliative Care Medicine.

Maybe, I am one of the few people here who has seen death from thirst.  It was in a newborn baby and is not something that is easily forgotten. I am reminded what Dame Cecily Saunders said ;

          “How people die remains in the memory of those who live on”.

In fact no one can survive without hydration and nourishment. They are basic human needs. The human body has a built in control system to ensure that fluid intake continues. Thirst is a primitive sensation which eventually comes to dominate all others and the thirst centre lies in the hypothalamus one of the deepest levels of the brain. There can be no certainty that drugs working on the higher centres will abolish thirst.

Baroness Knight took part in a recent Newsnight  discussion in which the President of the Association for Palliative Care Medicine stated that the dying do not experience thirst or that it can be relieved by moistening the mouth.

In fact Dr Peter McCullough a senior researcher at the John Curtain School of Medicine of the Australian National University in a review of the literature in 1996 quotes Fitzsimons and Barnard ;

          “…moistening the mouth failed to relieve thirst in dogs and horses  with oesophageal fistula …and it is evident that, whereas dryness of the mouth can aggravate a sensation of thirst resulting from body water depletion, its alleviation will not remedy thirst in the absence of correction of water depletion.”

As a recently as 2009 the distinguished  professor Sam Ahmedzai with long experience in Hospices writing in The Times said;

          “Hospices have always maintained that dying people  do not feel thirst and to die in a state of dehydration is “natural”,     and even desirable. I am struck by the stability of this view over several decades but in healthcare, such a focus would be seen as narrow minded inflexibility. Several studies have shown that dehydration can cause intense suffering and people recovering from severe life threatening illness in intensive care units recall thirst as one of the most distressing sensations. Dying people often cannot tell us how they feel, yet they will    probably experience the same feelings we all do when we are dehydrated. 

          The “evidence” against medically assisted hydration is largely based on the experience of intravenous fluids, which   admittedly can cause problems of fluid overload and the tubing can get in the way. For years however we have had the alternative method of subcutaneous hydration by which adequate fluids to counter thirst and distress can be administered by unobtrusive needles into the abdomen or thigh with hardly any risk of overload”.

 Following all the recent publicity on the Liverpool Care Pathway and the Westminster Hall Debate just after Parliament reassembled, a number of horrifying accounts have come to light of people dying of dehydration after 13 days without any fluids. Sometimes even after the families have begged doctors to reconsider and in one case actually seeking legal advise, but to no avail.

 In fact, the Liverpool Care Pathway does not prohibit subcutaneous fluids being administer but as the 2010 - 2011 audit makes clear it almost never happens and that over 80% of people put on the pathway have artificially administered fluids stopped. This has to be a severe criticism of the pathway itself as well as its application in practice.

 The Department of Health continues to endorse the Liverpool Care Pathway and Lord Howe has just made it plain that the Pathway itself is not  being questioned. It is still insisted that it is “good medicine”, and that is also the stated position of the three bodies currently carrying out the  inquiry established by Norman Lamb the Minister for Care.   How objective can they be about an inquiry into their own policies, one may ask?

It is to be hoped that not only will relatives be able to give their evidence directly to Baroness Julia Neuberger, the independent chairman of the inquiry  but that medical and scientific evidence critical of the Liverpool Care Pathway itself  as well as  its practice, can  be given directly to her.

Thank you for your kind attention.

 

Last Updated on Tuesday, 29 January 2013 21:38
 

Commentary on the Statement supporting the Liverpool Care Pathway

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The Statement supporting the Liverpool Care Pathway from the National End of Life Programme was published under multiple signatories. We have a number of serious reservations and questions about the working of the Liverpool Care Pathway.

1        The statement says, “it is not always easy to tell whether someone is very close to death”.

          The fact is that there is no scientific evidence to support the diagnosis of impending death and there are no published criteria that allow this diagnosis to be made in an evidence-based manner. This is even more true of non cancer conditions. This diagnosis is a prediction, which is at best an educated guess. Predictions have been shown to be often in serious error.

          There is no evidence that the diagnosis of impending death can be improved by using “the most senior doctor available “, and an actual misdiagnosis of impending death could result in a wrongful death.

 

2        “The Liverpool Care Pathway …is not a treatment”.

          This statement belies what actually happens once a patient is signed up onto the LCP. The fact that morphine, midozelam and glycopyrrolate are prescribed makes the LCP a treatment protocol.

 

3        The Liverpool Care Pathway …is…a framework for good practice.”

          In the twenty-first century all good clinical practice is evidence based. Good clinical practice has always traditionally involved a close doctor-patient relationship  and the management of symptoms in the best interest of the patient, as and when they arise. The LCP is more than a framework. It is a pathway that takes the patient in the direction of the outcome presumed by the diagnosis of impending death. The pathway leads to a suspension of evidence based practice and the normal doctor-patient relationship.

 

4        “The Liverpool Care Pathway does not….hasten death.”

          It is self evident that stopping fluids whilst giving narcotics and sedatives hastens death. According to the National Audit 2010-2011, fluids were continued in only 16% of patients and none had fluids started.

          The median time to death on the Liverpool Care Pathway is now 29 hours. Statistics show that even patients with terminal cancer and a poor prognosis may survive months or more if not put on the Liverpool Care Pathway.

          Your statement fails to mention the relief of symptoms at all. We think this is a serious omission. The question of consent is not mentioned either.

          If as you say, the LCP does not replace “clinical judgement”, and is a “framework for good”, why is it not endorsed by 28% of senior healthcare professionals?  (National Audit 2010-2011)

          Patients should receive an individual treatment plan according to best evidence based medicine. They should not be deprived of consciousness, but receive such treatment that is aimed at relieving all their symptoms including thirst. Nothing should be done which intentionally hastens death. An individual care plan based on best evidence is preferable to a rigid pathway.

 

Signed

 

Professor P Pullicino

Prof of Neurosciences

 

Mr J Bogle

Chairman Catholic Union of Great Britain

 

Dr P Howard

Chairman Joint Medico Ethical Committee Catholic Union

 

Dr R Hardie

President Catholic Medical Association

 

Dr A Cole

Chairman Medical Ethics Alliance   

 

Dr M Knowles

Secretary First Do No Harm

 

Mrs N  McCarthy

Cathlolic Nurses Association

 

Ms T Lynch

Chairman Nurses Opposed to Euthanasia

 

Mr R Balfour

President  Doctors who Respect Humen Life

 

Dr J Qureshi

Founding Chairman Health and Medical Committee

Muslim Council of Britain

 

21/10/12    

 

 

Welcome

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The Medical Ethics Alliance affirms the unique value of all human life, its God given dignity and consequent right to protection in law.

We are a non-profit organisation and have been established to promote pro-life policies.

We are certain that all persons are of inestimable worth, irrespective of illness or disability.

The pursuit and practice of medical excellence is dependant upon sound ethical principals.

The Alliance looks to the Declaration of Geneva for inspiration.

Click here to access MEA's journal 'Ethics and Wisdom in Medicine'.

Click here to see latest MEA Newsletter is online now.

Last Updated on Saturday, 14 November 2009 00:40
 

Tony Nicklison

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The Medical Ethics Alliance extend sincere condolences to the family of Tony Nicklison.

We wish to make it clear however that it is never, nor should it ever become incumbent upon doctors to kill the sick or assist in their suicide.

Like many in the last two weeks we have been humbled and amazed by the achievements of disabled athletes and believe they can teach us much about human dignity.

A Cole
Chairman

 

 


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