Observations Medicine and the Media

The assault on the Liverpool care pathway

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7316 (Published 30 October 2012) Cite this as: BMJ 2012;345:e7316
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}margaretmccartney.com

The Liverpool care pathway has recently come under fire, with newspapers accusing hospitals of using it to kill terminally ill patients, Margaret McCartney reports

The Daily Mail newspaper has set its guns on the Liverpool care pathway. On 25 October it stated, “After a Mail campaign, investigation is launched into controversial guidelines on ‘hastening death’.” It reported that because “the Mail has highlighted the growing fears of patients’ relatives and many doctors that the care pathway is really a way of hastening the deaths of terminally ill patients,” the Association for Palliative Medicine would review the guidance.

The Mail claimed, “The average lifespan of a patient on the pathway is 29 hours. Yet some patients who were taken off the pathway at the insistence of their relatives have lived for several months.” The next day the headline, filling about a third of the front page, was: “Hospitals bribed to put patients on pathway to death.” The story went on to explain: “The incentives have been paid to hospitals that ensure a set percentage of patients who die on their wards have been put on the controversial regime …At least £30 million in extra money from taxpayers is estimated to have been handed to hospitals over the last three years to achieve these goals.”1

The assault on the pathway continued inside. On 14 October, the columnist Melanie Phillips had written, “Horrifyingly, the LCP has become a self-fulfilling prophecy. When people are put on it, they are said to be dying. But they may not be dying at all—not, that is, until they are put on the ‘pathway’, whereupon they really do die as a result. In other words, they are killed. What’s more, they are killed in a most cruel and callous way through starvation or dehydration.”2

She went on to claim that the pathway was used to save money and that “more fundamentally, it has arisen from a profound confusion in society caused by a collapse of moral absolutes and a resulting inability to make the key distinction between dying and killing.” The Daily Mail’s editorial comment on 24 October claimed that “loved ones have been put on the LCP without the consent or knowledge of their families . . . perhaps the most disturbing objection is that medical science cannot predict with any certainty how long a patient may live with proper care . . . it is simply not enough just to say that doctors know best.”3

The problem with this reportage is the consequences it has for patients, families, and healthcare staff. Death has too often been regarded as medical failure rather than an inevitable consequence of life. The Liverpool care pathway was developed because of the acknowledgment that many terminally ill people were dying on general medical wards rather than in hospices or at home.4 The pathway focuses on control of symptoms, comfort, and alleviation of distress. It allows for the cessation of interventions, such as intravenous drugs, that are no longer of benefit, but it also has the flexibility to be rescinded where clinically appropriate.

Paradoxically, quality of life and the need for adequate pain relief for terminally ill people has been a previous concern of the Daily Mail. As far back as 1994, it said that palliative care was of poor quality in the United Kingdom, with “terminally ill [patients] denied right to a good death.”5 In 2010 the newspaper reported the Economist Intelligence Unit’s The Quality of Death report, saying, “The UK is best in the world at supporting people at the end of their lives.”6 In 2009 the newspaper published a story explaining how a dying man was in great distress and pain at the end of his life.7 In 2011 it published a feature describing the death of the writer’s mother, when a morphine syringe pump had been set up: “I’ll always be grateful to the GP who eased mum’s pain—even if it hastened her death.”8

Dying well should be a priority for healthcare professionals and managers. Yet the onslaught of scaremongering publicity over the Liverpool care pathway may simply increase fears about the appropriate use of humane analgesia—for patients, families, doctors, and nurses—and lead to more painful deaths. This is harmful. So too are allegations that are not backed up with fair evidence—for example, the question asked in the Daily Mail, “Did NHS kill my mother to free bed?” despite the fact that meetings offered by the hospital to explain the use of the pathway had not been taken up by the complaining relative.9

Melanie Phillips wrote that withdrawing food or water “is starving or dehydrating someone to death. And that is not helping them to die, but killing them.” This statement fails to acknowledge that the pathway does not preclude artificial hydration,10 but seems to insist that doctors must provide ineffective and potential harmful interventions of no value and at all costs, which is neither in the best interest of the patient or the ethics and duties of medical professionalism.

Nor does the Mail explain that in the context of the health and social care act, multiple targets and frameworks are used to judge hospitals’ performance; these are not bribes but typical sources of income. Singling out the Liverpool care pathway risks making it appear that this is an isolated and unusual case, when it is entirely usual.

More than 20 organisations, professional and voluntary, issued a statement backing the use of the Liverpool care pathway in October,11 and statements of support have also emerged from the Christian Medical Fellowship12 and from a chaplain writing for the Catholic Herald.13 Free speech in the press is a fundamental right. Criticising current procedures and practices can be useful, and newspapers should be free to do this. But doing so in a way that scaremongers and alleges that doctors are parties to “killings” is reprehensible and unfair to a highly vulnerable group of people and their families.

Notes

Cite this as: BMJ 2012;345:e7316

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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