Sentenced to death on the NHS
Patients
with terminal illnesses are being made to die prematurely
under an NHS scheme to help end their lives, leading doctors warn today.
under an NHS scheme to help end their lives, leading doctors warn today.
Kate Devlin - Daily
Telegraph - 02 Sep 2009
In a letter to The Daily Telegraph, 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across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.
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 Luke’s 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 Government’s 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 patient’s 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 patient’s 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
| What is the Liverpool Care Pathway? The Liverpool Care Pathway was developed to improve the care of patients in their dying hours and ensure that they were not being “overmedicalised”. It is described as a “template” to healthworkers to guide the care of the dying. It encourages doctors and other healthcare staff to consider removing medication and other treatments that no longer benefit the patient. The LCP also recommends that the situation should be discussed with relatives and if possible with the patient themselves. The guidance recommends that a patient's condition is regularly assessed. Patients can come off the pathway if the healthcare team treating them considers that they are no longer close to death. The LCP was developed by the Marie Curie hospital in Liverpool working with a team at the Royal Liverpool and Broadgreen University Hospitals Trust. Originally developed as a way to care for cancer patients towards the end of their life it has been adapted to apply to all patients no matter what their illness. |
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Millions of elderly patients prescribed unnecessary pills
because of 'tick-box culture', says expert
Jenny Hope - 04th March 2009
Doctors are giving patients prescriptions which are not required, according to Professor Michael Oliver
Millions of healthy older people are being prescribed pills that they don't need, claims a top doctor.
The treatments for high blood pressure, high cholesterol or diabetes could in fact be harmful, warns Professor Michael Oliver.
He blames the 'tick-box culture' - by which GPs are paid - and Health Service guidelines for encouraging the use of such drugs.
Professor Oliver, a former leading heart specialist, said: 'These bureaucratic demands can lead to over-diagnosis, overtreatment and unnecessary anxiety.
'A fit and healthy older person summoned by his GP for an annual health check can return home as a patient, scared and no longer comfortably ageing.'
Professor Oliver, professor emeritus of cardiology at the University of Edinburgh, launched his broadside against modern medicine in the British Medical Journal online.
He argues that 'many Western governments regard all people aged over 75 as patients'.
Other critics claim that even younger people, such as those in their 60s, are being treated in the same way because of the pressures for preventive prescribing.
Around ten million Britons are aged 65 or over. Professor Oliver said that even if older people feel reasonably well, the 'NHS does not always permit such euphoria'.
'They may be told they have hypertension or diabetes or high cholesterol, that they are obese, they take too little exercise, eat unhealthily and drink too much. Many of these patients are told to have more investigations. Eventually most will be started on pills. Few seem to be considered not at risk for something,' he said.
Yet preventive action may be irrelevant and even harmful in the elderly, he claims.
He highlighted three areas of concern - antihypertensive drugs, diabetes drugs and cholesterol-lowering drugs.
Antihypertensive drugs are used to reduce blood pressure and are usually prescribed for life. But as many as one in five patients experience side effects, from tiredness and fatigue to impotence and heart rhythm disturbances.
Diabetes drugs can cause diarrhoea, nausea and vomiting, and dangerously low blood sugar levels.
And cholesterol-lowering drugs, known as statins, interact with some other drugs and have side effects including abdominal pain, diarrhoea and nausea.
The most serious adverse reaction is muscle weakness in about one in 1,000 users, with rare complications that can lead to kidney failure and death.
Professor Oliver said that too little attention was paid to potential side effects from medicating elderly people.
Busy family doctors appear to assume that because a pill cuts the relative risk of a disease by 25 per cent compared with other or no treatments, it must be prescribed.
Yet the reduction in absolute risk to the individual - the chances of a medical emergency or death - may be only one or two per cent.
'What kind of medicine is this?' he asks. 'It is politics taking preference over professionalism, obsession with government targets superceding common sense, paternalism replacing personal advice.
'This trend has many causes. 'These include over-enthusiastic and uncritical interpretation of various guidelines, the payment of GPs by NHS trusts for ticking boxes, the demands of government health economics and of insurance companies, and the relentless pressure from the drug industry,' he concludes.
The professor said guidelines were not 'commandments' and rigid adherence can result in a superficial diagnosis that leaves someone stuck with the label of a disease for the rest of their life.
Professor Oliver, who describes himself as a healthy, fit, 83-year- old, said he was not arguing against treatment of disease or illness in over-75s, such as heart surgery, which clearly helped the individual.
But treating 'risk factors' must be approached with caution, he claims. 'The benefits and risks of treatment, and of remaining untreated, need to be explained fully to individuals, as it is they who should make the final choice.'
It has been claimed by health experts that mass medication might be the only answer to cut such problems as heart disease. Statins could cut heart attacks by 30 per cent, some doctors have calculated.
Gordon Lishman, Director General of Age Concern, said 'Doctors have a tightrope to walk. Inappropriate and excessive drug prescribing is a real issue, especially as many older people have lots of different, overlapping health complaints. 'The answer is to treat each person as an individual, by fully investigating all their health problems and offering them personally tailored treatment with the aim of maximising their overall health rather than treating each illness in isolation.'
Taking needless medication for high blood pressure, high cholesterol or diabetes could be harmful
Doctors today are increasingly being forced to work in a ' tickbox' culture - the treatment we give is determined less by clinical benefit than by diktat, largely as a result of Government imposed guidelines and growing supervision of our work.
This has led GPs to prescribe drugs when in many cases weight loss, exercise, and dietary change can be just as valuable.
The problem is that those changes are difficult and time-consuming - and, frankly, there's little political gain from these softer options, which is why there is no official pressure to introduce them.
There has also always been a trend for doctors to add new drugs to a patient's regimen: 'Let's see if this will help.' Most are then reluctant to reduce them, even if they have produced no obvious benefits, just in case something goes wrong.
All of this means that some patients end up on a rather impressive number of pills they might not need, as Professor Michael Oliver says.
In some cases the pills might actually put them at risk, such as blood pressure pills which could lead to too-low blood pressure if not needed.
In medicine, as in many walks of life, it is easier to be seen to act, rather than just to support and contemplate.
One of my patients is 88 and yet had needed to see a doctor only twice in her life when she first came under my care two years ago: in 1926 for tonsillitis, and in 2002 when she fractured her hip. Yesterday, when I went to see her for our regular chat, we marvelled together at her good fortune; taking no tablets at such an age.
She told me that quite a few of her friends had been critical when they have heard that she takes no treatment to lower her cholesterol, and I suddenly felt a bit guilty.
But her memory and intellectual functions are impressive, and she had already worked out that there was little to gain from such a regime at her age.
Masterly inactivity is what GPs have always done, and must continue to do, despite the pressure to prescribe.
Listening, and understanding, is a drug which doctors have always used and perhaps these days a drug which is falling from fashion.
Dr Scurr is one of the UK's
leading
GPs and answers your questions on health
every Tuesday in the Mail's Good Health.
every Tuesday in the Mail's Good Health.
See also:
Don't treat the old and unhealthy, say doctors
End-of-life care 'needs to improve in 40% of services'
The problem of defining death
Terminally ill people should be given hallucinogenic drugs to enhance experience of dying
Liverpool Care Pathway for the Dying Patient [33KB PDF]
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