Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A term impossible to define?
- Don C Aston (11 April 2008)
-
Continuous Deep Sedation in the UK- Dutch research reflects problems with the Liverpool Care Pathway
- Adrian J Treloar (14 April 2008)
-
Helpful Article
- Graeme M Mackenzie (14 April 2008)
-
Continuous Deep Sedation and LCP concerns
- Fiona M Downs, Angela Bentley, Michael Cornbleet, and Elizabeth Arnold (16 April 2008)
-
Re: Continuous Deep Sedation and LCP concerns
- Mary Knowles (17 April 2008)
-
Please, dont forget ethical responsibities
- Philip J. Harrison (22 April 2008)
-
Re: Continuous Deep Sedation in the UK- Dutch research reflects problems with the Liverpool Care Pathway
- John E Ellershaw (4 May 2008)
-
LCP concerns;- clarifications and an apology
- Adrian Treloar (6 May 2008)
-
Palliative care and sedation: the Liverpool Care Pathway
- Gillian M Craig (19 May 2008)
-
LCP - amend , don't abandon
- Ian N Back (21 May 2008)
|
|
|||
|
Don C Aston, retired Solihull B90 2BG
Send response to journal:
|
As an illustration of the difficulty of defining the terms ` terminal ` and/or ` palliative ` sedation even in hospice settings, the only review article ( Sedation and terminal care - Josep Porta Sales ) ever published in the European Journal of Palliative Care (2001; 8 (3)) found a median frequency of use of 25% but with a range of 1% to 72%. The review covered 13 articles published in the previous 10 years and at least confirms how long some form of end-of-life sedation has been as a component of hospice care. Competing interests: None declared |
|||
|
|
|||
|
Adrian J Treloar, Consultant and Senior Lecturer in Old Age Psychiatry Memorial Hospital London SE18 3RZ
Send response to journal:
|
The editorial [1] and paper on Continuous Deep Sedation [2] give evidence that Continuous Deep Sedation has been associated with a reduction in the frequency of euthanasia in the Netherlands. However, it is clear from the study that, often enough, Continuous Deep Sedation is used as a method which shortens life. It also stands to reason that sedating a patient who is ill with combinations of opiates, benzodiazepines and other medication will reduce their ability to eat, drink, breathe and survive. It is very clear that the use of such sedative medicines is, at times, right and proper;- these medicines have been given as part of good palliative care for years in the UK and elsewhere. But it is clear that Continuous Deep Sedation is only appropriate for the last few hours or days of life. The Rietjens study found that many patients were treated with Continuous Deep Sedation for up to a week or more. The study also found that almost all patients cared for by GPs or nursing home physicians had artificial nutrition and hydration withheld during the period of Continuous Deep Sedation. Sadly the researchers do not say if all nutrition and hydration was omitted. There are some important lessons here for UK practice. The Liverpool Care Pathway (LCP) is the UK’s main clinical pathway of Continuous Deep Sedation and is strongly promoted for roll out across the NHS [3]. In my view, this study highlights why some serious weaknesses the design of the LCP are important. Firstly, the LCP does not set out clear criteria for entry onto the pathway, which should ensure that only patients who are imminently dying are put onto it. The LCP’s eligibility criteria allow that a person, who is thought to be dying, is bed bound and unable to take tablets can go onto the pathway. And yet, in chronic diseases such as dementia the process of dying may be thought of as taking years, not days. Thus, patients with dementia who are far from death can be seen as eligible. Similarly, for example, patients with motor neurone disease who have a PEG tube fitted may be erroneously classed as eligible for the pathway. Reitjens’ paper shows that especially General Practitioners and those furthest from support, put patients onto such a pathway without palliative care advice. It therefore seems crucial that a pathway for general use minimizes opportunity for early or inappropriate use. As appears to be the case in Holland, the LCP can be inappropriately used before death is imminent. Murray et al conclude that there is legitimate concern that sedation should not be used as an inexpensive alternative to meticulous assessment and specialist treatment. At present, the LCP recommends prescription of sedative and opiate medication for all patients, and specifically recommends such prescription on an ‘as required’ basis, even for those who are not agitated, in pain or distressed. There are clear risks incurred by the marking out of an automatic pathway towards prescribing heavy sedatives. Moreover, there is a clear recommendation in the LCP that a syringe driver be set up within four hours of a doctor’s order. This is laudable, provided it is needed. But the pathway does, I think, tend by its structure, to err by encouraging syringe driver use even when symptoms can be properly managed without a syringe driver. Finally, and very importantly, the pathway makes no mention of the need for food and fluids. It is clear from the Reitjens study that withholding artificial nutrition and hydration is very strongly the norm. Murray et al. are right to state that nutrition and hydration should be considered on their own merits. The LCP’s omission of prompts to reconsider nutrition and hydration in any form may enable serious errors in the care of dying patients. It is surely not acceptable, as Murray et al suggest, that assessing the needs for and ways of giving nutrition and hydration are not even part of such a pathway. It is absolutely right to aim for the highest standards in end of life care, and sedation, in the correct dose, is a right and good thing where it is required. However, as Murray et al clearly point out, the anticipated outcome of Continuous Deep Sedation is death. So we must learn from the observation by Reitjens et al that Continuous Deep Sedation may replace euthanasia. If the methods and pathways that we use for Continuous Deep Sedation in the UK are flawed, then we will, at times, see patients die as a result of inappropriate use. In the light of this paper, I hope very much that the LCP will be reviewed and modified. [1] Scott A Murray, Kirsty Boyd, and Ira Byock Continuous Deep Sedation in patients nearing death BMJ 2008; 336: 781-782 [2] Rietjens J, van Delden J, Onwuteaka-Philipsen B, Buiting H, van der Maas P, van der Heide A. Continuous Deep Sedation for patients nearing death in the Netherlands: descriptive study. BMJ 2008 : 10.1136/bmj.39504.531505.25. [3] http://www.mcpcil.org.uk/liverpool_care_pathway Competing interests: None declared |
|||
|
|
|||
|
Graeme M Mackenzie, GP OUT OF HOURS North Cumbria
Send response to journal:
|
And this reinforces the need to be constantly reflective at the end of life as to whether more can be done. However as an out of hours GP who is thrown regularly into terminal care situations at home over a long weekend (the out of hours period covers 66 % of the week), seeking specialist palliative care advice is often difficult. This article fits well with other evidence that doctors are not good at end of life prognostication(something the out of hours GP has to do quickly and with no previous knowledge of the patient). Competing interests: None declared |
|||
|
|
|||
|
Fiona M Downs, Consultant in Palliative Medicine Strathcarron Hospice FK6 5HJ, Angela Bentley, Michael Cornbleet, and Elizabeth Arnold
Send response to journal:
|
We share Adrian Treloar’s concerns and comments regarding the LCP (Liverpool Care Pathway) [1] in his Rapid Response to the editorial [2] and paper [3] on Continuous Deep Sedation and have also worried about patients being commenced on the pathway inappropriately. For some time, we have felt that a Pre-LCP checklist would be appropriate in ensuring that patients did not commence the LCP prematurely and to this end FD devised CELT (Checklist for embarking on End of Life Treatment) [4] which we have piloted at Strathcarron Hospice in Forth Valley in Central Scotland [5]. Essentially CELT is a decision-making framework designed to achieve appropriate transition from active treatment to end-of-life care and to bridge the gap between GSFS (Gold Standard Framework) and the LCP. It highlights the importance of excluding reversible causes of deterioration and can be re-used if there is an improvement following specific treatment, e.g. for hypercalcaemia, and then a further decline. CELT could provide documented auditable evidence of a logical structured approach to end of life treatment and thus may also be helpful in averting/resolving complaints of either too much or too little treatment at the end of life. General Practitioners and District Nurses in Forth Valley have found it to be a helpful concept and we are currently discussing routine use of CELT in local acute and community hospitals. We would be happy to provide a copy of the CELT Tool if it was thought to be useful in other settings. Refs. 1. http://www.mcpcil.org.uk/liverpool_care_pathway 2. Scott A Murray, Kirsty Boyd, and Ira Byock Continuous Deep Sedation in patients nearing death BMJ 2008; 336: 781-782 3. Rietjens J, van Delden J, Onwuteaka-Philipsen B, Buiting H, van der Maas P, van der Heide A. Continuous Deep Sedation for patients nearing death in the Netherlands: descriptive study. BMJ 2008 : 10.1136/bmj.39504.531505.25. 4. CELT – A Checklist for Embarking on End of Life Treatment Downs F Strathcarron Hospice 2007 5. Use of the Checklist for Embarking on End of Life Treatment Arnold A, Downs F, Bentley A Poster presentation for 7th Paliative care Congress, Glasgow, April 2008 Competing interests: None declared |
|||
|
|
|||
|
Mary Knowles, Previously an anaesthetist but now retired Retired
Send response to journal:
|
Euthanasia implied intervention to hasten death. Alice Ricciardi-von Platen (Obtituary The Times 16.4.08) noted in her book recounting the history of the killing of the mentally ill in Germany that the doctor collaborators convinced themselves that they had a forward looking approach to their patients best interests. This ideology persists. Many Dutch physicians instituting continuous deep sedation with an irreversible condition and death expected at most one to two weeks consider they are providing high quality end of life care. However in 2007 international pallative care experts decided that sedation is a valid option when other treatments do not relieve symptoms in a patient expected to die within hours or days. This decision is to be made in consultation with a pallative care specialist, Midazolam, a short acting benzodiazepine being the sedative of choice. By careful titration against symptoms the paitent can communicate intermittently and request fluids. This high quality end of life care in the patient's best interests. A patient may want to reconsider i.e. terms of his will or to end a bitter family feud. The study unfortunately discovered that only 9% of Dutch general practioners had previously sought the advice of a pallative care specialist. The editorial comments that last year 43% non-compliance with the Dutch prescribing guidelines for terminal sedation was reported.This fact suggests that continuous deep sedation could be euthanasia masquerading under a different name. Mary Knowles Chair Doctors Who Respect Human Life Competing interests: None declared |
|||
|
|
|||
|
Philip J. Harrison, General Practitioner Upper Hutt, Wellington, NZ
Send response to journal:
|
A caveat to the assumption that terminal and/or palliative sedation can be accepted as the norm by health care professionals is that patients and their relatives should be contacted and their wishes, where possible, properly obtained. This is not as straightforward as it sounds.
My own previously well and robust 92 year old father was admitted as a medical emergency with rectal haemorrhage. He had 3 weeks earlier moved to live in a rest home due to deteriorating health of uncertain cause having spent all of his life living independently and in robust health (and fully lucid). On admission his haemoglobin was about 60G/L and initial resuscitation, blood transfusion, was successful. However, an urgent abdominal CT scan showed a locally invading colonic carcinoma at the splenic flexure. Of course, there was little chance he might survive surgery or, at least, long after it and terminal sedation was decided upon. Neither he (I later discovered) nor any of his close family were consulted prior to such a decision and treatment was immediately implemented. My brother and I, his only first degree relatives, were both overseas and we chose to return to the UK to be with him. He arrived the next day only to discover he was deeply unconscious. He lived three days in total until 2 hours after I arrived at the hospital. At this point he was warm, well perfused with a good CV output - so hardly haemorrhaging to death. So after a 36 hour shuttle across the world having learned he was sitting up chatting vowing to recover (admittedly pre-diagnosis) to find him close to death was a little distressing. No drip, heavy sedation increasingly infused. Protocol successful, patient died quietly with his family. No goodbyes. All those experiencing events over that time - all long standing friends and then my non-medical brother - overwhelmed by the 'integrity' of medical intervention and "what must be done". All seemingly confused by what was evolving. I was quite upset to learn that my father had no knowledge of his fate and I therefore chose to investigate his care in more detail. I was then able to confirm that he had never consented to terminal sedation and although he knew his condition was not curable (not documented), he was certainly not aware that he would shortly die as was evidence by the statements he made to friends. And as his sons were flying to his side surely he would have wanted to see and talk to us before he died? Isn't that obvious? Obviously not. Of course, once the facts were established, I received a profound and honest apology from the hospital, but I had only received this after they had initially incorrectly made a statement in writing that he had received terminal sedation because he was "distressed" and "in pain". Not only was this refuted by visitors but the notes made no reference to pain or distress, whatsoever. By all accounts he was actually feeling quite well. So was this terminal euthanasia in another guise....or was this worse? So let us not assume that relieving the stress of the dying is a universal excuse for removing the problem and denying human rights of those involved and a dignified death as perceived by all interested parties. Relieve distress in all its manifestations, yes, but no automatic right of the 'Pathways of Care' lobby to 'pull the plug' just because someone is going to die anyway. My plea is firstly to ascertain why such therapy is being utilised and in whose name and DOCUMENT this with written signatures of those whom have the authority to make such decisions (the patient AND/or the next of kin). If the patient cannot do this AND the next of kin are uncontactable, terminal sedation should be deferred until contact is objectively deemed to be impossible. Terminal sedation is not simply to expedite demise in order to free up costly specialist facilities. Far better to discharge such patients to Hospice Care where caring for the terminally ill is done with greater expertise and sensitivity. I only discovered these facts because I am a doctor and had the 'brass neck' to ask. I am quite concerned what could well be going on out there in the name of caring and terminal sedation. Look this gift horse in the mouth I would say. Competing interests: Father was subjected to terminal sedation courtesy of medical / nursing team. |
|||
|
|
|||
|
John E Ellershaw, Professor of Palliative Medicine University of Liverpool
Send response to journal:
|
I read with interest the response to the recent paper on continuous deep sedation by Adrian Treloar which illustrated a number of dangerous misconceptions about the purpose and use of the Liverpool Care Pathway for the Dying Patient (LCP) that need to be addressed. Firstly, the LCP is not “the UK’s main clinical pathway of Continuous Deep Sedation” as suggested. The LCP is an integrated care pathway that supports clinical decision making amongst non-specialists. Its purpose is to promote the comfort of patients (physical, emotional, spiritual) in the last days of life and to address the needs of informal carers at this time. The control of symptoms in the last days of life is an important element which in some cases does involve the use of sedation. The algorithms, provided as examples within the pathway, support the titration of appropriate drugs (using the minimum required and against the individual needs of the patient) to achieve symptom control rather than ‘continuous deep sedation’ as claimed. The assertion that ‘the LCPs eligibility criteria allow that a person who is thought to be dying, is bed bound and unable to take tablets can go on the pathway’ is also rather incomplete and misleading. Commencing a patient on the LCP is dependent on a decision being made by the multi- disciplinary team that the patient is ‘dying’ and that all reversible causes for the patient’s deterioration have been considered. The four criteria – bed bound, only able to take sips of fluid, unable to take tablets, comatose or semi comatose are provided merely as reference points to aid such decision making. A checklist summarising the patient’s condition at the time of the decision to commence an LCP provides a useful baseline summary against which the decision to discontinue the use of the pathway can be made should the patient’s condition improve, which can occur in between 3% and 5% of patients. The most important challenge regarding the use of the LCP remains the failure to put patients on the pathway who are clearly dying. The LCP does indeed recommend the prescription of drugs for the five main symptoms in the final days of life on a prn basis even when the patient may not be currently displaying any of these symptoms. However, it does not demand the use of sedation or opioids in all cases, only that these drugs are available if distressing symptoms arise. This has ensured that many dying patients have not waited for hours to have distress treated because of unavailable drugs or unwritten PRN prescriptions. In addition, it was suggested that the fact that ‘…the LCP recommends setting up a syringe driver within four hours of a doctor’s order’ encourages syringe driver use even when symptoms can be managed without a syringe driver. There is no requirement in the LCP to set up a syringe driver in all cases, only if a regular antiemetic, opioid or sedative is needed. This avoids the need for frequent injections and erratic symptom control. Data from the national audit of care of the dying undertaken in 118 hospitals across England in 2006/2007 illustrates that, on commencement of the pathway, a syringe driver was not deemed necessary for 32% of 2,672 patients who died on an LCP. The statement that ‘the pathway makes no mention of the need for food and fluids’ is, again, inaccurate. Clinicians are reminded of the importance of thinking about such issues in goal 3 of the pathway. Here, decisions about whether interventions such as blood tests, antibiotics and the administration of IV fluids and medications are still felt to be conferring benefit to each individual patient commenced on a pathway are made. This ensures that only those deemed to be doing so are continued. Evidence from the national audit clearly illustrates that, on commencement of the pathway, in 15% of cases IV fluids/medications were continued. This finding implies individual clinical decision making in response to the perceived needs of patients. As with other Integrated Care Pathways in the healthcare arena, the LCP is subject to a process of regular reflection and evaluation. I welcome the comments of all who have suggestions for its further development and the continual improvement of care for dying patients. J E Ellershaw Professor of Palliative Medicine, Marie Curie Palliative Care Institute Liverpool, University of Liverpool Competing interests: I am the Director of the Marie Curie Palliative Care Institue Liverpool whose portfolio includes the Liverpool Care Pathway for the Dying Patient (LCP) Framework |
|||
|
|
|||
|
Adrian Treloar, Consultant and Senior Lecturer in Old Age Psychiatry Memorial Hospital, London SE18 3RZ
Send response to journal:
|
Professor Ellershaw, Dr Regnard and other palliative care specialists have firmly told me that the LCP is not a form of deep sedation. I am happy to accept that, properly used, the LCP is not deep sedation and thus in these circumstances my use of the term ‘deep sedation’ for the LCP is misplaced. I apologise for this. While I recognise that many have found the LCP helpful, it was experiences of medical staff and relatives, similar to that so movingly described by Dr Harrison [1] which first brought concerns about the LCP to my notice. Of course, excessive sedation must be inappropriate [2]. Dr Regnard felt that I was saying that all people placed on the LCP are given syringe drivers. This was not the case. I merely tried to set out goal 3b of the LCP which states that a “syringe driver is set up within four hours of a doctors order”. [3] Given that others read that to mean that all patients are given a syringe driver, I do find it odd that the same statement ought not to give rise to concerns when it is part of the LCP. It is, of course the case that syringe drivers are neither indicated in all those who are dying, nor given to all such people whether they are on the LCP or not. But my concern is that while goal 2 involves prescribing as required medicines, the pathway then considers things to discontinue, and then goes straight to a goal of setting up a syringe driver on the order of a doctor, without considering alternatives as fully as I feel it should. It is for this reason that I do worry that the pathway does, at times, encourage syringe drivers ahead of alternatives. Excellent as is the aim of having a syringe driver available within four hours if it is needed, it would seem to me to be much better if there was merely a target that all appropriate medications were available on such a time scale. I remain concerned about the issue of reliably diagnosing death, particularly in specialities such as mine, in which imminent death may be less diagnosable than imminent death from cancer. I am heartened to hear that Downs, et al [4] and Keiley [5] all share this concern and hope very much that future modifications of the pathway will reduce the risk of being entered onto the pathway at the wrong time. Certainly, in my field of dementia care the criteria do seem extremely loose. Given that there will sometimes be people who are put onto the pathway when they are not imminently dying (clinical error being impossible to remove entirely from medicine), I am also very pleased to hear that others also share my worry that assessment of hydration is not a routine part of the LCP. [5] . Professor Ellershaw says that fluids are part of goal 3, but to be fair, iv fluids are only listed as something to consider discontinuing [3]. Moreover, following the initial assessment, nutrition and hydration are also absent from the ongoing care part of the pathway. I worry more that a real assessment of continued nutrition and hydration is important. Some colleagues have told me that not considering the issue of nutrition and hydration means that the pathway is neutral on this issue and suggested that failure to give appropriate fluids is poor clinical care rather than a failure of the pathway. But any care pathway needs to identify places in which clinical error is most likely to occur and make provision for this. So while, of course, there will be times when even oral nutrition and hydration is too burdensome (due perhaps to severe swallowing problems or dyspnoea) I do feel that the decision not to give food and fluid must be a part of a properly made clinical decision. Otherwise the issue may be forgotten. Moreover, with ongoing prompts to think about appropriate nutrition and hydration, the risks of putting people who are not imminently dying onto the pathway may also be reduced. I would reiterate the hope expressed in my previous letter, that the LCP will be reviewed and modified, and that some of the problems which I see with it and hear of from others, will be rectified. We need the best possible palliative care in this country, and clinicians do need guidance. In my field of dementia care, there is a real need to improve understanding of palliative and supportive medicine as well as to just do it better. I am grateful for the comments and responses to date and would once more say I am sorry if my use of words in my original letter was not as clear as I had hoped. [1] Dr P Harrison http://www.bmj.com/cgi/eletters/336/7648/781 [2] Dr Paul Vooght LCP Concerns http://www.bmj.com/cgi/eletters/336/7650/905#194761 [3] http://www.mcpcil.org.uk/files/LCPCAREHOMEVERSIONprintableversion.pdf [4] Continuous Deep Sedation and LCP concerns Fiona M Downs, Angela Bentley, Michael Cornbleet, and Elizabeth Arnold http://www.bmj.com/cgi/eletters/336/7648/781 [5] Amend but don’t abandon the LCP. Keily M. http://www.bmj.com/cgi/eletters/336/7650/905#194739 Competing interests: None declared |
|||
|
|
|||
|
Gillian M Craig, Vice Chair Medical Ethics Alliance a retired Consultant Geriatrician
Send response to journal:
|
I have followed the online debate about continuous deep sedation in patients nearing death with growing concern, for the debate is in danger of being sidelined by semantics. Dr Adrian Treloar need not have apologised for using the term ‘continuous deep sedation’ in relation to the Liverpool Care Pathway (LCP) (1). It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills. Palliative carers try to reassure the worried public by saying that some patients (in fact a mere 3-5% according to Ellershaw) improve when placed on the LCP (2). There are always exceptions that prove the rule! Patients with heart failure that has been made worse by fluid overload may improve when drips are stopped. Patients who have been made worse by their medication may improve when the offending drugs are stopped. The lucky few will recover when placed on the LCP- (providing that someone notices their improvement and takes them off the pathway in time), but the great majority will die. Therefore before putting anyone on the LCP doctors should be confident of their clinical diagnosis. They should have considered and tried to treat any reversible factors and they should be capable of accurately predicting close proximity to inevitable death. But these are counsels of perfection and doctors are fallible. A recent study has shown that health care professionals in a hospice setting are wrong 50% of the time when predicting patient survival (3). Such is the pressure to roll out the LCP nationwide that many patients, especially the frail elderly, are at risk of having their lives shortened prematurely. That may suit economists and politicians with eyes on the balance sheet rather than the patient, and it may suit those who resent having elderly bed-blockers on their wards, but it is not good medicine. Poor end of life care undermines the trust between doctors and their patients. It is surely time to put the LCP on hold until all the concerns that have been raised online at http://www.bmj.com and elsewhere (4,5) have been carefully considered. It is time for those who advocate sedation without hydration at the end of life to examine their motives. It is time for the medical profession to take collective responsibility for end of life care, for this topic is far too important to be left to palliative carers and the Department of Health. We must not allow ourselves to be driven by individuals or organisations with vested interests or by quasi- governmental committees meeting behind closed doors. It is time to say enough is enough! Yours truly, Dr Gillian M Craig.
References and notes. 1. Adrian J. Treloar . LCP concerns:-clarifications and an apology. (6 May 2008) http://www.bmj.com/cgi/eletters/336/7648/781. accessed 14.05.08. 2. John E. Ellershaw . Re: Continuous deep sedation in the UK-Dutch research reflects problems with the Liverpool Care Pathway. (4 May 2008) http:/www as above. 3. Feargal Twomey, O’Leary N, O’Brien T. Prediction of patient survival by healthcare professionals in a specialist palliative care inpatient unit: a prospective study. American Journal of Hospice Care, Vol 25 No 2. April/May 2008, p139-145. DOI:10.1177/1049909107312594 4. Gillian Craig. Palliative care in overdrive: patients in danger. American Journal of Hospice and Palliative Care, Volume 25 No 2, April/May 2008, p 155-160. DOI:10.1177/1049909107312596 5. For a decade of debate about sedation without hydration see Craig GM (Ed) “No Water-No Life: Hydration in the Dying”. Fairway Folio 2005. ISBN 0 9545445 3 6. Available from Medical Ethics Books PO Box 341 Northampton NN3 2WZ. E mail books341@clara.co.uk. Competing interests: None declared |
|||
|
|
|||
|
Ian N Back, Consultant in Palliative Medicine Y Bwthyn Palliative Care Unit, Pontypridd, CF37 4AL and Holme Tower Marie Curie Hospice, Penarth
Send response to journal:
|
As a supporter of the LCP, and the similar All-Wales Care Pathway[1] which we use, I welcome Dr Treloar's gracious retraction of some of his original comments, but his misunderstanding is perhaps understandable. When teaching colleagues about the care pathway, I find it necessary to anticipate a number of potential misunderstandings, including the issues of eligibility criteria, and IV fluids. The sample pathway available from the LCP website[2] shows criteria for use of the LCP. These can quite easily be misread to imply that any patient with a terminal illness who has two of the listed criteria (bedbound, only able to take sips of fluid, semicomatose, or unable to take tablets) is appropriate for the pathway. This is clearly not the intention, and I commend Fiona Downs for her work on a pre-pathway decision-making framework. The precise wording in the (sample) pathway also leads to difficulty. For example, the sample pathway states that Goal 3 is to "Discontinue inappropriate interventions" under which it lists IV fluids as one part. The answer options are Yes, No and N/A. There are two potential problems with this form of wording: 1) If a decision is made to continue with IV fluids after careful consideration, it is unclear whether to tick Yes (I do not consider IV fluids to be inappropriate) or No (I have not discontinued them). 2) If the doctor ticks No, there is the implicit pressure that they have failed to meet one of the goals. As a checklist to ensure that all dimensions of care are considered when attending a dying patient, the pathway is invaluable and should not be cast aside. However, it is now used widely by staff who are not palliative care specialists, and a meticulous review and revision of the wording of the LCP (and All-Wales pathway) is warranted. [1] Fowell A, Finlay I. A good death. Care pathway in Wales aims to improve care of dying patients. BMJ 2000;320(7243):1206 [2] Sample of Hospital LCP pathway. Available at: www.mcpcil.org.uk/files/LCPHOSPITALVERSIONprintableversion.pdf (Accessed 20 May 2008) Competing interests: None declared |
|||