Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The LCP - Good care at the end of life; not hastening death.
- Lulu Kreeger (26 April 2008)
-
Treolar misrepresents Liverpool care pathway
- Claud Regnard (26 April 2008)
-
Amend, but don't abandon the LCP
- Mary T Kiely (26 April 2008)
-
End of Life Care
- Gregory T Gardner (4 May 2008)
-
LCP concerns
- Paul F. Vooght (4 May 2008)
-
Assessing dying
- Bruno Bubna-Kasteliz (12 May 2008)
-
More responses to this letter
- Adrian Treloar (15 May 2008)
|
|
|||
|
Lulu Kreeger, Consultant Palliative Medicine Kingston Hospital NHS Trust and Princess Alice Hospice, Esher
Send response to journal:
|
Adrian Treloar in his letter in the BMJ 26/4/08 misunderstands the fundamental premise of the Liverpool Care Pathway (LCP). A patient is only put on the pathway once it is recognised they are dying imminently, ie within hours to short days. (1) In this context and in this time frame, the evidence does not support that artificial hydration or nutrition has a role to ease symptoms and suffering and may, in fact, add to it. (2) In keeping with the National Council for Palliative Care’s guidance on artificial hydration and nutrition, that a blanket policy either for, or against, the use of artificial hydration and nutrition at the end of life is ethically indefensible, an individual can justify maintenance of artificial fluid or nutrition within the LCP, which would then be documented as a variance. As part of good care, patients will be supported to maintain oral fluids/food as long as they can, but as part of the dying process, this ability will be lost. The prime focus for patients and those close to them is that they are comfortable, supported and treated in a dignified way. The proactive prescribing of medications for comfort is essential to ensure that any symptoms that develop are swiftly managed, with only so much medication, targeted to the symptom, as is needed. If medication is given in the absence of symptoms, this is poor practice to be challenged. Syringe drivers are only a mode of delivery when the oral route is lost. Some patients die without the need for syringe drivers. Deep sedation is not recommended as part of the LCP and is not usual practice in UK Palliative Care teaching. Sedation can be a feature of symptom management, but is not the prime aim. Hence morphine will be used to treat pain or breathlessness, glycopyrronium to treat bubbly secretions, haloperidol to treat nausea or agitation/delirium, midazolam to treat distress etc. The majority of patients do not need large doses of these medications to achieve the necessary symptom control. In a study from St Christopher’s Hospice, dose increases in sedative medication at the end of life were not associated with a shortened survival. (3) The key assessment is the identification of dying. The focus of care is then clarified and the LCP provides a structured format to achieve this. It is unhelpful to raise concerns about hastening death by deep sedation or denying hydration and only fuels misunderstanding and fear. The introduction of the LCP must be supported by a comprehensive teaching programme and the structure of the tool supports regular evaluation and audit. The LCP is not a fete acompli to dying and occasionally patients get better and come off the pathway. In the acute general hospital I work in, where we have supported over 300 patients on the LCP, this has occurred on 14 occasions. This is an essential time to be effective clinicians. Poor experiences of dying will resonate in relatives’ memories. The LCP supports clinicians to get it right. References: 1. Marie Curie Palliative Care Institute. Liverpool Care Pathway for the dying patient (LCP), 2008. http://www.mcpcil.org.uk/liverpool_care_pathway; 2. C Campbell, R Partridge. Artificial Nutrition and Hydration. Guidance in end of life care for adults. The National Council for Palliative Care, May 2007. 3. Sykes N and Thorns A; The use of opioids and sedatives at the end of life. Lancet Oncology; 2003 May;4(5):312-8. Competing interests: None declared |
|||
|
|
|||
|
Claud Regnard, Consultant in Palliative Care Medicine St. Oswald's Hospice, Newcastle-upon Tyne, NE3 1EE
Send response to journal:
|
Treolar’s misrepresentation of the Liverpool care pathway does a disservice to an initiative that has changed end of life care in the UK.(1) The pathway does not demand the use of sedation or opioids in all cases, only that these are available if distressing symptoms arise. This has ensured that thousands of dying patients do not wait for hours to have distress treated because of unavailable drugs. There is no requirement to set up a syringe driver in all cases, only if a regular antiemetic, opioid or sedative is needed. The pathway does not restrict the use of hydration or any other comfort measures that may be needed. Finally, even if sedation is needed, this is always titrated to the individual using the minimum needed, not ‘continuous deep sedation’ as Treolar claims. It is good to see palliative care in print, but more care is needed to ensure this describes current practice. References 1) Treolar AJ. Dutch research reflects problems with the Liverpool care pathway. 2008; BMJ; 336: 905. Competing interests: None declared |
|||
|
|
|||
|
Mary T Kiely, Consultant in Palliative Medicine Huddersfield Royal Infirmary, HD3 3EA
Send response to journal:
|
Contrary to Dr Treloar's concerns, continuous deep sedation is not an instruction of the Liverpool Care Pathway (LCP). The anticipatory prescribing of drugs to be administered when, and only when, distressing symptoms develop, is at the heart of advance care planning. However, some clarification may indeed be required. When we introduced an end-of-life care pathway in our Trust five years ago, we felt that the existing entry criteria for the LCP were too broad (many post-operative patients would also qualify!) and we therefore created our slightly amended Care of the Dying Pathway. Central to this are its initial three eligibility criteria: firstly, that the patient has advanced, progressive and life-threatening disease; secondly, and crucially, that reversible causes for the current deterioration have been considered and appropriately managed; and finally, that intensive treatments such as cardiopulmonary resuscitation and ventilation are deemed futile and inappropriate. We also allowed for the consideration of artificial hydration, where clinically appropriate, and highlight the importance of thorough assessment. The majority of dying patients will not require deep sedation, but end-of-life care pathways are vital in guiding those doctors and nurses less familiar with, and confident in, the management of the terminal phase. In these days of reduced medical continuity in patient care, it is also essential that doctors continue to exercise clinical judgement when assessing patients whose condition is deteriorating. Competing interests: None declared |
|||
|
|
|||
|
Gregory T Gardner, GP Principal Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR
Send response to journal:
|
As a non specialist I contribute to this debate with hesitancy. Nevertheless, in spite of the laudable aims of the Liverpool Care Pathway to manage symptoms in the terminally ill and to stop all futile measures, I agree with Adrian Treloar and Mary Kiely that assessment of hydration is an important omission. For some terminally ill patients dehydration may exacerbate other symptoms such as agitation or confusion. Correction of dehydration by the use of subcutaneous fluids may in some patients be helpful.1 The use of terminal sedation in the absence of proper assessment and correction of dehydration is bad medicine and at its worst (as in Holland) can be a substitute for euthanasia. 1 Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient? Support Care Cancer 1997;5:205-11. Competing interests: None declared |
|||
|
|
|||
|
Paul F. Vooght, Associate Specialist Garden House Hospice SG6 1QU
Send response to journal:
|
Dr A. Treloar is right to draw attention to the potential dangers of inappropriate terminal sedation when patients are put on the LCP. They need to be properly assessed and regularly reviewed. Having drugs prescribed just in case should not make it more likely to sedate patients to death but with pressure on beds and financial pressure it is not inconceivable to see patients being sedated inappropriately. Patients in certain environments eg hospices may be more assured of this proper assessment and regular review than others in other areas eg nursing homes. We need to develop our palliative care services in the community. Competing interests: None declared |
|||
|
|
|||
|
Bruno Bubna-Kasteliz, Professional Adviser Office of Health Ombudsman, Millbank, London W1P 4QP
Send response to journal:
|
With 30 years' experience as a geriatrician, I always found it difficult to predict death, which is what is being sought here, in order to implement the LCP appropriately. While the LPC offers useful guidelines on the management of end-of-life symptoms, it seems to be rushing in with sedation and opiates without considering whether hydration and nutrition are also still valid treatment. Competing interests: None declared |
|||
|
|
|||
|
Adrian Treloar, Consultant and Senior Lecturer in Old Age Psychiatry SE18 3RZ
Send response to journal:
|
There are additional responses to this letter posted [1] under responses to the original editorial by Murray et al, from Fiona M Downs et al, Mary Knowles, Prof John Ellershaw as well as clarifications with an apology from Adrian Treloar. [1] http://www.bmj.com/cgi/eletters/336/7648/781 Competing interests: None declared |
|||