By Kate Devlin, Medical Correspondent Published: 10:00 PM BST 02 Sep 2009
In a letter to The Daily Telegraph (http://www.telegraph.co.uk/comment/letters/6133157/Dying-patients.html) ,
a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death.
Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.
Under the guidelines the decision to diagnose that a patient is close to death is made by the entire medical team treating them, including a senior doctor .
But this approach can also mask the signs that their condition is improving, the experts warn. As a result the scheme is causing a national crisis in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Lukes cancer centre in Guildford, and four others. Forecasting death is an inexact science,they say. Patients are being diagnosed as being close to death without regard to the fact that the diagnosis could be wrong.
As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients." The warning comes just a week after a report by the Patients Association estimated that up to one million patients had received poor or cruel care on the NHS. The scheme, called the Liverpool Care Pathway (LCP), was designed to reduce patient suffering in their final hours. Developed by Marie Curie, the cancer charity, in a Liverpool hospice it was initially developed for cancer patients but now includes other life threatening conditions.
It was recommended as a model by the National Institute for Health and Clinical Excellence (Nice), the Governments health scrutiny body, in 2004. It has been gradually adopted nationwide and more than 300 hospitals, 130 hospices and 560 care homes in England currently use the system.
Under the guidelines the decision to diagnose that a patient is close to death is made by the entire medical team treating them, including a senior doctor. They look for signs that a patient is approaching their final hours, which can include if patients have lost consciousness or whether they are having difficulty swallowing medication. However, doctors warn that these signs can point to other medical problems. Patients can become semi-conscious and confused as a side effect of pain-killing drugs such as morphine if they are also dehydrated, for instance.
When a decision has been made to place a patient on the pathway doctors are then recommended to consider removing medication or invasive procedures, such as intravenous drips, which are no longer of benefit. If a patient is judged to still be able to eat or drink food and water will still be offered to them, as this is considered nursing care rather than medical intervention. Dr Hargreaves said that this depended, however, on constant assessment of a patients condition. He added that some patients were being wrongly put on the pathway, which created a self-fulfilling prophecy that they would die.
He said: I have been practising palliative medicine for more than 20 years and I am getting more concerned about this death pathway that is coming in. It is supposed to let people die with dignity but it can become a self-fulfilling prophecy. Patients who are allowed to become dehydrated and then become confused can be wrongly put on this pathway. He added: What they are trying to do is stop people being overtreated as they are dying. It is a very laudable idea. But the concern is that it is tick box medicine that stops people thinking. He said that he had personally taken patients off the pathway who went on to live for significant amounts of time and warned that many doctors were not checking the progress of patients enough to notice improvement in their condition. Prof Millard said that it was worrying that patients were being terminally sedated, using syringe drivers, which continually empty their contents into a patient over the course of 24 hours.
In 2007-08, 16.5 per cent of deaths in Britain came about after continuous deep sedation, according to researchers at the Barts and the London School of Medicine and Dentistry, twice as many as in Belgium and the Netherlands.
If they are sedated it is much harder to see that a patient is getting better, Prof Millard said. Katherine Murphy, director of the Patients Association, said: Even the tiniest things that happen towards the end of a patients life can have a huge and lasting affect on patients and their families feelings about their care.
Guidelines like the LCP can be very helpful but healthcare professionals always need to keep in mind the individual needs of patients. There is no one size fits all approach.
A spokesman for Marie Curie said: The letter highlights some complex issues related to care of the dying. The Liverpool Care Pathway for the Dying Patient was developed in response to a societal need to transfer best practice of care of the dying from the hospice to other care settings.
The LCP is not the answer to all the complex elements of this area of health care but we believe it is a step in the right direction.
The pathway also includes advice on the spiritual care of the patient and their family both before and after the death. It has also been used in 800 instances outside care homes, hospices and hospitals, including for people who have died in their own homes.
The letter has also been signed by Dr Anthony Cole, the chairman of the Medical Ethics Alliance, Dr David Hill, an anaesthetist, Dowager Lady Salisbury, chairman of the Choose Life campaign and Dr Elizabeth Negus a lecturer in English at Barking University.
A spokesman for the Department of Health said: People coming to the end of their lives should have a right to high quality, compassionate and dignified care. "The Liverpool Care Pathway (LCP) is an established and recommended tool that provides clinicians with an evidence-based framework to help delivery of high quality care for people at the end of their lives.
"Many people receive excellent care at the end of their lives. We are investing £286 million over the two years to 2011 to support implementation of the End of Life Care Strategy to help improve end of life care for all adults, regardless of where they live.
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