Tuesday, October 9, 2012

The UK tightens guidelines to prevent euthanasia by dehydration.

In June 2012, an article published by Professor Patrick Pullicino claimed that 130,000 people die each year in the UK by intentional dehydration based on the use of the Liverpool Care Pathway.

The Liverpool Care Pathway is a guideline to be used when a person is approaching the final days of life. The guideline enables a physician to withdraw fluids, food and all medical treatment from a person

An article that was written by Steve Doughty and published in the Daily Mail on June 19, entitled: Killing patients who are difficult to manage is becoming common in the UK stated that the Liverpool Care Pathway is used on 450,000 people every year, and the article quoted Pullicino as stating that 29% of those deaths are actually caused by the Liverpool Care Pathway.

Dr Peter Saunders
Another article was written by Dr. Peter Saunders, the Campaign Director for the Care Not Killing Alliance, that was entitled: Is the NHS actually killing 130,000 patients a year with the Liverpool Care Pathway? This article acknowledged that abuse is occurring with the Liverpool Care Pathway, but it questioned whether 130,000 deaths were actually caused by the Pathway and it also suggested that the problem was not with the Liverpool Care Pathway guidelines but rather the inappropriate use of the Pathway.

Saunders stated:
If a patient is judged to be imminently dying and is placed on the LCP and dies within hours or days one can be virtually certain that the death was caused by the underlying condition. 
However, on the other hand, if a patient is placed on the pathway and has hydration and nutrition removed whilst being sedated and dies, say ten-fifteen days later, then there must be a very real question about whether the withdrawal of hydration actually contributed to the death. But to put a patient on the LCP for this length of time is quite inappropriate.
I have no doubt that there are some patients who are not imminently dying who are being placed on the LCP inappropriately in Britain as Professor Pullicino has alleged. 
However this is not the fault with the pathway itself but rather relates to its inappropriate use. Any tool is only useful if it is used with the proper indications. 
In response to the outrage related to the inappropriate use of the Liverpool Care Pathway, the NHS (National Health Service) has now amended the guidelines for the Pathway making it mandatory that two doctors agree before a person is placed on the Pathway.

An article written by Steve Doughty and published on October 1 in the Daily Mail - UK entitled: Two doctors must agree to use controversial 'death pathway' for patients in their final days states:

A number of other senior medical figures have questioned the removal of nourishment and hydration by tube from some patients, and one pressure group has begun issuing cards to patients that tell hospitals they do not want to be put on the Liverpool Care Pathway. 
The call for at least two medical staff to assess patients – one of whom should be the most senior on duty – was issued in a ‘consensus statement’ by 20 bodies including the Royal College of General Practitioners, the Royal College of Physicians, the National Council for Palliative Care, pressure groups including Age UK and the Alzheimer’s Society, and the Royal College of Nursing. 
They said the LCP could bring ‘substantial benefits to people who are dying and their families’. The statement added: ‘It is not always easy to tell whether someone is very close to death – a decision to consider using the pathway should always be made by the most senior doctor available, with help from all the other staff involved in a person’s care. It should be countersigned as soon as possible by the doctor responsible for the person’s care.
The article then stated:
The statement also said that the withdrawal of fluids and food by tube was not always necessary. 
The pathway, it said, ‘does not preclude the use of clinically assisted nutrition or hydration – it prompts clinicians to consider whether it is needed and is in the person’s best interest. 
‘We support the appropriate use of the Liverpool Care Pathway and make clear that it is not in any way about ending life, but rather about supporting the delivery of excellent end-of-life care.’
Wesley Smith
Bioethicist, Wesley Smith commented on the NHS changing its Liverpool Care Pathway in an article titled: UK tries to prevent backdoor euthanasia. Smith stated:
Palliative sedation is an appropriate remedy in extreme cases: It is not intended to cause death. Indeed, it can be titrated and levels of sedation varied depending on circumstances.  In other words, it isn’t the same thing as “terminal sedation,” often used in the Netherlands by doctors who sedate patients whose conditions do not require it, after which sustenance is withdrawn as a way of causing death–which can take up to two weeks. Disturbing recent reports have shown that about 10% of Dutch deaths are caused by this kind of backdoor euthanasia, and indeed, that doctors are using it in place of lethal injection. 
The motives of the Pathway creators were beneficent and not intended to create a situation like in the Netherlands. I hope these changes of protocol refocus care to the individual patient in the bed. But given the intense centralization of the NHS, I worry when the deemed solution to mistakes caused by bureaucratic medicine–appears to be more bureaucratic medicine.
We hope that the UK will properly control the use of the Liverpool Care Pathway. It is also necessary in Canada, and other countries, to properly monitor end-of-life decision making.

Many people wrongly state that withdrawing life-sustaining treatment is the same as euthanasia. There is a clear difference between killing someone and letting them die. When properly monitored, the withdrawal of life-sustaining treatment is not the same as euthanasia and the decision to withdraw fluids and food, in the final hours of life, is most often related to allowing a peaceful and natural death to occur.

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