End of life care in the acute hospital setting
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5048 (Published 01 December 2009) Cite this as: BMJ 2009;339:b5048
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Editor, The editorial by Edmonds et al (1) on end of life
care in acute hospital settings and the improved guidance on
use of the Liverpool care pathway (version 12) is assuring.
I think in acute physical health hospitals the use of the
guidance is relatively straight forward. Granted I have not
seen to date a comparative audit of use of the Liverpool
care pathway in acute physical health hospital settings as
opposed to acute psychiatric hospital setting caring
dementia patients, it is the use of the pathway in the
latter settings that may need some refinement. Different
authors have tried to address the issue of end of life care
issues in patients with severe dementia. The research
evidence is sparse (2), with some authors being of the view
that management of end stage dementia(ESD) with comorbidity
and disability may prove more difficult than physical health
only end stage illness (3). There is therefore potential for
more variation in how psychiatrists caring for ESD patient
may use the Liverpool pathway, as compared to their physical
care colleagues. One author has devised the mini suffering
scale examination (MSSE) (3), for use in such situations, as
a decision tool. He goes as far as to propose the "Aminoff
suffering syndrome" as an indication that the patient with
ESD should be given a dignified exit from his/her suffering.
I would think that this very vulnerable group of patients
(ESD) will need some degree of palliative care protection
to avoid the slippery slope of “killing them as opposed to
letting them die with dignity” by way of better guidance to
the use of the pathway in patients with ESD.
References
1.Edmonds P, Burman R, Prentice W. End of life care in the
acute hospital setting. BMJ 2009;339:b5048. Accessed
December 4th, 2009.
2.Van der Steen JT, Ribbe MW. Dying with dementia: what do
we know about it? (original article in Dutch). Tijdschr
Gerontol Geriatr. 2007(6):288-97.
3.Aminoff BZ. Relief of suffering with dementia units.
Dementia 2009 8407-415.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir/Madam,
I applaud the Liverpool Care of the dying Pathway (LCP). However, I feel
that there is an underrecognised cohort of patients - those that are near
the end of life but not yet actually diagnosed as dying. These are often
the elderly in patient that then deteriorates on the acute hospital ward
before going on to die. They may then be the subject of a lottery for
treatment - some being potentially subjected to innappropriate
interventions such as cardiopulmonary resuscitation, whilst others may be
put "Not For Resuscitation" which can often mean even simple measures
aimed at trying to save the patient are neglected e.g. antibiotics and
oxygen. For these patients we need a framework comparable to the LCP to
guide care across the range of treatment modalities, which is discussed
and planned in advance of any acute deterioration. At least for those
patients in this group that go onto die (and are the subject of an LCP)
they would have received appropriate care upto the point of the diagnosis
of dying is made.
In our hospital we have been using such a framework - a Treatment
Escalation Plan (TEP) - for 3 years. Anecdotally the end of life care we
give has been greatly enhanced, over and above the strides forward in care
the LCP has allowed us to deliver.
Competing interests:
None declared
Competing interests: No competing interests
Implementing the Liverpool Care Pathway
Dear Editor, More than training will be needed to implement the
Liverpool care pathway (LCP) The LCP has to be embedded into existing,
complex, healthcare structures and ways of working, so a whole systems
approach is required. When my 95-year-old father was admitted to hospital
with a mild heart attack, he was given a good prognosis. During the three
weeks he was in hospital it proved impossible to even organise a set of
dentures, (after not wearing his dentures for a few days following
admission, he found that they no longer fitted), so what chance of
convening a multidisciplinary team, at short notice and out of hours, to
decide that my father is dying and the LCP should be instigated? He was in
great pain from a ‘small’ bed sore during his last few days. On what would
turn out to be his last evening, I appealed to the nurse on duty for
morphine for Dad. She agreed that he was unlikely to survive beyond the
next 24 hours. Her persistence in trying to get hold of a doctor paid off,
and a prescription, eventually, was issued. Her ambivalence was evident
though, when she said to me, “You do realise this (morphine) will shorten
his life.”
Competing interests:
None declared
Competing interests: No competing interests