There is more than one way to skin a cat, the old politically incorrect saying goes. There is also more than one way to euthanize a patient. In England, there is concern that a legitimate pain controlling treatment—known as palliative sedation—is being used inappropriately under what is known as the Liverpool Care Pathway, to make people dead.
Here's the background. Several years ago, reacting to legitimate complaints that dying patients were receiving inadequate pain control, well-meaning pain control experts created a protocol to help doctors determine when it was proper to apply palliative sedation. PS is a legitimate medical treatment that puts patients near the end of their lives whose symptoms cannot otherwise be controlled, into an artificial coma until they die from their underlying disease.
Palliative sedation is not killing. As an article in the Journal of Pain & Palliative Care Pharmacotherapy (201 2;26:30-39) put it earlier this year (abstract link only): "Palliative sedation is not a euphemism that is morally equivalent to euthanasia, nor is it "slow euthanasia," or physician-assisted suicide (PAS)." Indeed, the article made three essential points about palliative sedation, properly applied:
- PS is individualized to the terminally ill patient's needs;
- PS doesn't end the life of the patient but prevents otherwise untreatable pain; and,
- Levels of sedation may vary in the same patient from time to time. In other words, it is to be applied in a nuanced and patient-specific manner.
The point of the Pathway was to ensure that patients who need palliative sedation receive it, not to make it standardized practice. But that has not been how the protocol has been applied. Indeed, almost from the beginning, there were bitter complaints that the LCP was being used in cases that did not require sedation, and indeed, was used to sedate and dehydrate non terminally ill patients—a form of euthanasia known as "terminal sedation," which, isn't a medical treatment at all.
For example, in 2009, the Times of London reported:
An 80-year-old grandmother who doctors identified as terminally ill and left to starve to death has recovered after her outraged daughter intervened. Hazel Fenton, from East Sussex, is alive nine months after medics ruled she had only days to live, withdrew her antibiotics and denied her artificial feeding. The former school matron had been placed on a controversial care plan intended to ease the last days of dying patients. Doctors say Fenton is an example of patients who have been condemned to death on the Liverpool Care Pathway plan.
Fenton lived to tell the tale. Not so for 76-year-old Jack Jones. Jones was hospitalized in the belief that his previous cancer had recurred and was now terminal. The family claimed he was soon denied food and water and put into deep sedation. But his autopsy showed that he did not have cancer at all, but actually had a treatable infection. The hospice denied wrongdoing but paid £18,000 to Jones's widow.
After these and other cases, the bureaucrats that control the National Health Service promised to review practices and ensure that the LCP was only applied when warranted by the patient's condition. If they tried, they appear to have failed. The Daily Mail has now reported that a prominent medical professor claims that, if anything, the abuses of the Pathway are increasing:
NHS doctors are prematurely ending the lives of thousands of elderly hospital patients because they are difficult to manage or to free up beds, a senior consultant claimed yesterday. Professor Patrick Pullicino said doctors had turned the use of a controversial 'death pathway' into the equivalent of euthanasia of the elderly. He claimed there was often a lack of clear evidence for initiating the Liverpool Care Pathway, a method of looking after terminally ill patients that is used in hospitals across the country…There are around 450,000 deaths in Britain each year of people who are in hospital or under NHS care. Around 29 per cent – 130,000 – are of patients who were on the LCP.
That is an astonishing charge, which we should note, has been vehemently denied by medical authorities. But it is very clear to me that if more than a few percent of patients are on the Pathway at any given time, it is being overly applied—perhaps even, intentionally abused.
So, why are too many patients in the UK apparently on the Pathway? I think it is a direct consequence of bureaucratizing of healthcare. The purpose of the LCP was to assure that the few patients with unrelievable pain do not die in agony. But centralized control leads to follow-the-dots medicine in which patients are often treated as members of a category rather than as individuals. At that point, nuance can easily go out the door.
We can't solve the UK controversy from here, but we can learn some important lessons. For example, if Obamacare or some other centralized system rules American healthcare, medical practice here could become as sclerotic as it appears to be in the United Kingdom. Indeed, the law already calls for the creation of many cost/benefit/best-practices boards of the kind that led to adoption of the Liverpool Care Pathway. Making matters more alarming, these boards would not only govern treatment provided under Medicare and Medicaid, but also are empowered to set the standards of care paid for treatments paid for by private insurance.
If we allow centralized control over medical care—whether under Obamacare or a successor law—don't be surprised when one dark day, an American version of the Liverpool Care Pathway comes soon to a hospital or nursing home near you.