Hazardous Pathway

The United Kingdom continues to provide vivid warnings about the dangers of centralized health-care planning — a real possibility under Obamacare. Within the last few years, the U.K.’s notorious rationing board, the National Institute for Health and Clinical Excellence (NICE), urged hospitals, nursing homes, and hospices to follow an end-of-life protocol known as the Liverpool Care Pathway. The Pathway’s guidelines instruct doctors to put patients thought to be near death into a drug-induced coma, after which all food and fluids, as well as medical treatments such as antibiotics, are withdrawn until death.

The problem with such a protocol is that no matter how well motivated — and undoubtedly, the Pathway’s creators had good intentions — follow-the-dots medical protocols often lead to patients’ being treated as members of a category rather than as individuals. At that point, nuance often goes out the door, and mistakes, neglect, and even oppression frequently follow.

That seems to be precisely what has happened with the Pathway as it has been applied in hospitals, nursing homes, and hospices throughout the U.K. Angry family members are beginning to come forward, charging that their loved ones have been sedated and had food and water withdrawn — whether their symptoms warranted these measures or not. Indeed, some have alleged that their deceased relatives would have lived but for having been put on the Pathway to death. These stories have all the early hallmarks of a full-fledged medical scandal.

The problems with the Pathway, at least as sometimes applied, first came to light in an open letter in the Daily Telegraph, signed by palliative physicians and others:

Just as, in the financial world, so-called algorithmic banking has caused problems by blindly following a computer model, so a similar tick-box approach to the management of death is causing a national crisis in care. The government is rolling out a new treatment pattern of palliative care into hospitals, nursing homes, and residential homes. It is based on experience in a Liverpool hospice. If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death.

A concurrent Telegraph story reported that 16.5 percent of patients who died in 2007–08 expired while under “continuous deep sedation,” i.e., an artificial coma. That figure struck me as exceedingly high. I have spoken to several hospice professionals about “palliative sedation,” as it is sometimes called, and all claimed that it is rarely necessary to treat pain or to relieve other distressing symptoms. And in those few cases in which a patient must be rendered unconscious, the measure is undertaken so late in the disease process that it is generally not the cause of death.

In this regard, Dr. Eric Chevlen, a pain-control expert and former hospice medical director, told me: “In close to 30 years of practicing oncology and palliative care, I have treated hundreds of patients with opioids to relieve pain, accepting some level of sedation as an unavoidable side effect rather than the goal of therapy. But I can recall only a handful of times in which I felt that the best way I could reduce the patient’s suffering was to intentionally diminish his level of consciousness.”

This raises the suspicion that more dying patients are rendered unconscious in the U.K. due to the Pathway than would be warranted if each patient were treated based on his symptoms. If so, the Pathway protocols may be being applied in some cases without regard to proper proportionality of dosing based on each patient’s need, and without adhering to Hippocratic standards of individualized care — both of which are important ethical concerns. Indeed, this practice raises the suspicion that the Liverpool Care Pathway may have become a platform for backdoor euthanasia. Tellingly, the Telegraph reported that twice as many patients in the U.K. die while under deep sedation as do in the Netherlands — a country where terminal sedation sometimes serves as a substitute for active euthanasia.

After the doctors’ letter was published, Pathway supporters fought back, claiming that family members were actually quite satisfied with the treatment their loved ones had received, and had been relieved that the protocol allowed all to die in peace, without pain. That seemed to be the end of the matter — but then, the horror stories began to come to light.

On September 8, the Daily Telegraph carried a story in which one Rosemary Munkenbeck charged that after her father was hospitalized with a stroke, he was quickly deprived of fluids and medications. She further claimed that doctors wanted to sedate him with morphine until he died, under the Pathway protocols, but the family refused. Munkenbeck’s father went five days until sustenance was restored, but the family isn’t hopeful. “We believe that he has been forced down this route,” she told the Telegraph. “By withdrawing fluids he is now very weak and there’s no going back from it.”

Soon, the Times of London reported another case:

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. They argue that while it is suitable for patients who do have only days to live, it is being used more widely in the NHS, denying treatment to elderly patients who are not dying.

Fenton lived to tell the tale. Not so 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.

This is precisely the paint-by-the-numbers medical approach that Obamacare threatens to bring across the pond to our shores. Indeed, former senator Tom Daschle — whom the New York Times called the most influential adviser to the president in the health-care debate — has long urged that America adopt NICE-style centralized medical planning. Indeed, according to Scott Gottlieb, writing in the Wall Street Journal, Daschle “argues that the only way to reduce spending is by allocating medical products based on ‘cost effectiveness.’ He’s also called for a ‘federal health board’ modeled on the Federal Reserve to rate medical products and create central controls on access.”

Chillingly, current Obamacare plans call for the creation of many cost/benefit/best-practices boards, the full power of which won’t be fully known until the bureaucrats promulgate tens of thousands of pages of regulations between now and 2013, when the law would go into effect. Making matters more alarming, these boards would not only govern treatment provided in any public-option health plan, but would also be empowered to set the standards of care paid for by private insurance. Unless the final version of Obamacare is amended explicitly to prohibit such centralized health planning, don’t be surprised if an American version of the Liverpool Care Pathway comes soon to a hospital or nursing home near you.