The last few weeks have not been a particularly auspicious time to be a member of the British medical profession.
This month, it has been suggested that I regularly practice euthanasia. I’ve been accused of manslaughter and of murder. I’ve been told that I’m killing off elderly patients in order to meet my bed managers’ targets and that I will choose to end the life of people who I think are worthless.
Well, not me. Everyone.
There are a handful of journalists, who admittedly mostly work for the Daily Mail and are therefore not really journalists, who have declared war on the Liverpool Care Pathway and, mostly by association but also a little bit by calling us arrogant and high-handed, have also declared war on all doctors everywhere.
The Liverpool Care Pathway For The Dying Patient, or the LCP, is an integrated set of guidelines, developed based on the hospice model, that is used to improve the quality of life in the final few days and hours of a patient’s life. It is used in patients in whom a diagnosis of dying has been made. If used correctly, it involves the stopping of most treatments and the starting of palliative medications where those are appropriate; the stopping of investigations and routine checks of heart rate, blood pressure, and so on; decisions being made about the appropriateness of fluid or nutrition based on whether those things will make a patient more comfortable rather than using them to artificially prolong their life; carrying out regular checks to ensure that the pathway is still appropriate and that no changes need to be made to it; and making sure that social and spiritual support, where wanted, has been made available to both the patient and their family. If a patient rallies and no longer appears to be dying – and the fact that this is a thing, both because doctors are sometimes wrong anad because sometimes miracles happen, seems to have become a huge source of scandal rather than the cause for celebration that I would hope it might be — the diagnosis of dying is reversed and the LCP is stopped.
It has been in use in the NHS for over a decade.
And, suddenly, kind of from out of nowhere, there are articles and the op-eds and the commenters who, honestly, to read them, you would think that Hitler was a fluffy bunny rabbit compared with British doctors.
I don’t take death nearly as lightly as they seem to think I do, and nor does anyone I work with. I am never less than saddened when one of my patients is given a terminal diagnosis and it is never anything less than a solemn thing when I go to pronounce someone dead or to see someone in the mortuary. The first time I was asked to start a patient on the LCP and the first time I was asked to pronounce a patient dead were on the same day, for the same patient, on my first weekend on call, when I had been a doctor for two weeks. I hadn’t eaten anything or stopped moving for ten hours, but I sat down in the doctors’ office on that ward and I cried buckets.
There is a body of opinion that says that it would support the use of the Liverpool Care Pathway in hospice medicine, which, they say, is where it was originally designed to be used, but think that it is inappropriate to use it in hospitals. But to do that would be to miss the whole point of the LCP — designed in a hospice, yes, in a place where end-of-life care is done very well and where they never actually needed the LCP, but with the express intention of taking those principles of good end-of-life care and putting them into a format that could be easily used in hospitals, where end-of-life are has often been done terribly. It is disingenuous to suggest that a pathway that enables the good management of dying patients is useful in hospices, where 16% of cancer patients died in 2003; but that it is inappropriate for use in a hospital, where 55% of cancer patients died in 2003. I guarantee that those numbers would be even more skewed for non-cancer patients.
Professor Peter Millard, emeritus professor of geriatrics at the University of London and therefore a man who really ought to have known better, is quoted in the British Medical Journal this week as saying, “In practice, it’s time consuming on the people doing it, and it doesn’t seem that once a person is on it, they can come off it. It is not flexible enough to be changed or sophisticated enough to take into account that person’s particular circumstances.”
The LCP can be used well or it can be used badly. If it’s used well, it is a wonderful thing and highly flexible and, sorry, Professor Millard, but we do take patients off it. If it’s used badly, it’s a failure of education and training and communication and occasionally circumstance – and the answer to that isn’t to get rid of the LCP itself. And, yes, starting someone on the LCP is time consuming, but, you know, taking care of a dying person is time consuming and, if we’re doing it right, so it damn well should be.
I find the implication that I want my patients to die to be deeply deeply offensive.
I want my patients to live. I want them to go home to their children and their grandchildren, whole and healthy, and to live long enough to forget that they ever knew a young doctor with glasses and a Geordie accent. It happens, sometimes, I hope. The days when I can hand over a discharge letter with a handshake and a smile and a teasing admonishment that I don’t want to see them again, those are good days.
But part of doing what I do is learning to accept that, sometimes, people die, and that, sometimes, there is absolutely nothing that can be done to change that, and that the only thing that can be done is to make sure that, when it happens, it’s with as much comfort and dignity as possible. There are good deaths and there are bad deaths. If you’ve seen a bad death, you won’t ever forget the difference. And the days when I know that a dying patient has slipped away painlessly and peacefully and with their family around them, those, through the tears that we don’t ever let fall in public, those are good days too.