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End of life
Liverpool Care Pathway: life-ending pathway or palliative care pathway? Mohamed Y Rady,1 Joseph L Verheijde2 Wrigley disagreed with the decision to phase out the Liverpool Care Pathway (LCP) from clinical practice in end-of-life care of terminally ill and dying patients in England.1 The decision was made by the Department of Health based on the recommendation of an independent review by Neuberger.2 In his analysis, Wrigley outlined some of the potential harms to patients from indiscriminately applying the LCP in clinical practice. The Neuberger Review outlined some of the fatal flaws in the LCP: (1) life-ending decisions were made in patients who might not have been imminently dying; (2) basic medical care was withheld or withdrawn (including nutrition and hydration) early in the end-of-life trajectory; and (3) pharmacological means of symptom control were administered that might have been more lethal than palliative.2 There is no highquality evidence supporting the palliative benefit of LCP in end-of-life care of terminally ill patients.3 4 Savulescu has argued that starvation and dehydration with palliative sedation can be integrated into end-of-life care in England.5 However, the efficacy of common palliative drugs in the management of distress following life-ending starvation and dehydration is unknown.6 Early starvation and dehydration in the end-of-life trajectory can exacerbate pre-existing distressful symptoms.7 Metabolic consequences of dehydration can diminish the efficacy of sedatives and analgesics in symptom control and, paradoxically, exacerbate distress from the side effects of these drugs such as hyperalgesia, agitation and delirium. Recognising that the clinical manifestations of starvation and dehydration can be refractory to sedatives and analgesics, the Royal College of Physicians has included terminal induction of general anaesthesia after the withdrawal of nutri-
1
Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA; 2Department Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA Correspondence to Dr Mohamed Y Rady, Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East mayo Blvd, Phoenix, Arizona 85054, USA; [email protected]
644
Provenance and peer review Commissioned; internally peer reviewed.
To cite Rady MY, Verheijde JL. J Med Ethics 2015;41:644.
tion and hydration in prolonged disorders of consciousness (vegetative and minimally conscious states).8 The media were instrumental in casting the light on the harm of LCP in end-of-life care. Endorsements of professional societies do not necessarily prove the trustworthiness or the safety of clinical practice guidelines. In fact, the Institute of Medicine has outlined requirements for formulating trustworthy guidelines.9 The LCP failed to meet these requirements. The Neuberger Review reached the same conclusion and justifiably recommended that LCP should be phased out.2 When a new drug or medical device is introduced into clinical practice, continuous surveillance for safety is essential to prevent harm to patients. Abandoning the LCP is no different from discontinuing a new drug or medical device that had resulted in preventable harm. Unfortunately, avoidable harm in end-of-life care is often ignored since death is the ultimate outcome.10 LCP was introduced into clinical practice without appropriate safety oversight, and belatedly withdrawn only after public complaints and media coverage brought attention to this harm. The design of end-of-life care pathways must be supported by highquality evidence demonstrating effectiveness and safety in the cohort of patients for which it was intended.11 A trustworthy end-of-life care pathway should also incorporate and respect the values and beliefs of patients and families.12 Palliative care is the comprehensive management of physical, psychological, spiritual and social well-being of patients and their families at the end of life. LCP failed to meet these objectives in clinical practice. The centrepiece of LCP became starvation, dehydration and deep sedation until death. Whether or not due to financial incentives associated with LCP compliance, this lifeending pathway became a self-fulfilling prophecy and potentially formed a backdoor to non-consensual active euthanasia. We think the abandonment of LCP illustrates a growing rejection of utilitarianbased moral decision-making models that discard the traditional values and foundations of medicine, implicitly obfuscating euthanasia as palliative care.
Received 10 June 2014 Accepted 27 June 2014 Published Online First 18 July 2014
▸ http://dx.doi.org/10.1136/medethics-2013-101533 ▸ http://dx.doi.org/10.1136/medethics-2013-101780 ▸ http://dx.doi.org/10.1136/medethics-2014-102424 J Med Ethics 2015;41:644. doi:10.1136/medethics-2014-102314
REFERENCES 1
2
3
4
5
6
7
8
9
10
11
12
Competing interests None.
Rady MY, et al. J Med Ethics August 2015 Vol 41 No 8
Wrigley A. Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review. J Med Ethics 2015;41:639–43. Department of Health. Review of Liverpool Care Pathway for dying patients: report on the use and experience of the Liverpool Care Pathway (LCP). UK, England: 15 Jul 2013. https://www.gov.uk/ government/publications/review-of-liverpool-carepathway-for-dying-patients (accessed 23 May 2014). Costantini M, Romoli V, Leo SD, et al. Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial. Lancet 2014;383 (9913):226–37. Currow DC, Abernethy AP. Lessons from the Liverpool care pathway—evidence is key. Lancet 2014;383(9913):192–3. Savulescu J. A simple solution to the puzzles of end of life? Voluntary palliated starvation. J Med Ethics 2014;40(2):110–3. Ivanovic N, Buche D, Fringer A. Voluntary stopping of eating and drinking at the end of life—a ‘systematic search and review’ giving insight into an option of hastening death in capacitated adults at the end of life. BMC Palliative Care 2014;13(1):1. Rady MY, Verheijde JL. Continuous deep sedation until death: palliation or physician-assisted death? Am J Hosp Palliat Care 2010;27(3):205–14. Royal College of Physicians. Prolonged disorders of consciousness: National clinical guidelines. London: RCP, 2013. http://www.rcplondon.ac.uk/sites/default/ files/prolonged_disorders_of_consciousness_ national_clinical_guidelines_0.pdf (accessed 23 May 2014). Institute of Medicine (IOM), National Academy of Sciences. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press, 2011. http://www.nap.edu/openbook.php?record_ id=13058 (accessed 23 May 2014). MacKintosh D. Death as “Harm” when it is an anticipated outcome in palliative care—or anywhere. J Palliat Med 2014;17(5):502. Chan RJ, Webster J. End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database Syst Rev 2013;11:CD008006. Montori VM, Brito J, Murad M. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA 2013;310 (23):2503–4.
Downloaded from http://jme.bmj.com/ on August 9, 2015 - Published by group.bmj.com
Liverpool Care Pathway: life-ending pathway or palliative care pathway? Mohamed Y Rady and Joseph L Verheijde J Med Ethics 2015 41: 644 originally published online July 18, 2014
doi: 10.1136/medethics-2014-102314 Updated information and services can be found at: http://jme.bmj.com/content/41/8/644
These include:
References Email alerting service
Topic Collections
This article cites 9 articles, 3 of which you can access for free at: http://jme.bmj.com/content/41/8/644#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections End of life decisions (ethics) (321) End of life decisions (geriatric medicine) (321) End of life decisions (palliative care) (321) Hospice (113) Pain (anaesthesia) (17) Pain (palliative care) (20) Assisted dying (191) Psychology and medicine (211)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
End of life
Liverpool Care Pathway: life-ending pathway or palliative care pathway? Mohamed Y Rady,1 Joseph L Verheijde2 Wrigley disagreed with the decision to phase out the Liverpool Care Pathway (LCP) from clinical practice in end-of-life care of terminally ill and dying patients in England.1 The decision was made by the Department of Health based on the recommendation of an independent review by Neuberger.2 In his analysis, Wrigley outlined some of the potential harms to patients from indiscriminately applying the LCP in clinical practice. The Neuberger Review outlined some of the fatal flaws in the LCP: (1) life-ending decisions were made in patients who might not have been imminently dying; (2) basic medical care was withheld or withdrawn (including nutrition and hydration) early in the end-of-life trajectory; and (3) pharmacological means of symptom control were administered that might have been more lethal than palliative.2 There is no highquality evidence supporting the palliative benefit of LCP in end-of-life care of terminally ill patients.3 4 Savulescu has argued that starvation and dehydration with palliative sedation can be integrated into end-of-life care in England.5 However, the efficacy of common palliative drugs in the management of distress following life-ending starvation and dehydration is unknown.6 Early starvation and dehydration in the end-of-life trajectory can exacerbate pre-existing distressful symptoms.7 Metabolic consequences of dehydration can diminish the efficacy of sedatives and analgesics in symptom control and, paradoxically, exacerbate distress from the side effects of these drugs such as hyperalgesia, agitation and delirium. Recognising that the clinical manifestations of starvation and dehydration can be refractory to sedatives and analgesics, the Royal College of Physicians has included terminal induction of general anaesthesia after the withdrawal of nutri-
1
Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA; 2Department Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA Correspondence to Dr Mohamed Y Rady, Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East mayo Blvd, Phoenix, Arizona 85054, USA; [email protected]
644
Provenance and peer review Commissioned; internally peer reviewed.
To cite Rady MY, Verheijde JL. J Med Ethics 2015;41:644.
tion and hydration in prolonged disorders of consciousness (vegetative and minimally conscious states).8 The media were instrumental in casting the light on the harm of LCP in end-of-life care. Endorsements of professional societies do not necessarily prove the trustworthiness or the safety of clinical practice guidelines. In fact, the Institute of Medicine has outlined requirements for formulating trustworthy guidelines.9 The LCP failed to meet these requirements. The Neuberger Review reached the same conclusion and justifiably recommended that LCP should be phased out.2 When a new drug or medical device is introduced into clinical practice, continuous surveillance for safety is essential to prevent harm to patients. Abandoning the LCP is no different from discontinuing a new drug or medical device that had resulted in preventable harm. Unfortunately, avoidable harm in end-of-life care is often ignored since death is the ultimate outcome.10 LCP was introduced into clinical practice without appropriate safety oversight, and belatedly withdrawn only after public complaints and media coverage brought attention to this harm. The design of end-of-life care pathways must be supported by highquality evidence demonstrating effectiveness and safety in the cohort of patients for which it was intended.11 A trustworthy end-of-life care pathway should also incorporate and respect the values and beliefs of patients and families.12 Palliative care is the comprehensive management of physical, psychological, spiritual and social well-being of patients and their families at the end of life. LCP failed to meet these objectives in clinical practice. The centrepiece of LCP became starvation, dehydration and deep sedation until death. Whether or not due to financial incentives associated with LCP compliance, this lifeending pathway became a self-fulfilling prophecy and potentially formed a backdoor to non-consensual active euthanasia. We think the abandonment of LCP illustrates a growing rejection of utilitarianbased moral decision-making models that discard the traditional values and foundations of medicine, implicitly obfuscating euthanasia as palliative care.
Received 10 June 2014 Accepted 27 June 2014 Published Online First 18 July 2014
▸ http://dx.doi.org/10.1136/medethics-2013-101533 ▸ http://dx.doi.org/10.1136/medethics-2013-101780 ▸ http://dx.doi.org/10.1136/medethics-2014-102424 J Med Ethics 2015;41:644. doi:10.1136/medethics-2014-102314
REFERENCES 1
2
3
4
5
6
7
8
9
10
11
12
Competing interests None.
Rady MY, et al. J Med Ethics August 2015 Vol 41 No 8
Wrigley A. Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review. J Med Ethics 2015;41:639–43. Department of Health. Review of Liverpool Care Pathway for dying patients: report on the use and experience of the Liverpool Care Pathway (LCP). UK, England: 15 Jul 2013. https://www.gov.uk/ government/publications/review-of-liverpool-carepathway-for-dying-patients (accessed 23 May 2014). Costantini M, Romoli V, Leo SD, et al. Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial. Lancet 2014;383 (9913):226–37. Currow DC, Abernethy AP. Lessons from the Liverpool care pathway—evidence is key. Lancet 2014;383(9913):192–3. Savulescu J. A simple solution to the puzzles of end of life? Voluntary palliated starvation. J Med Ethics 2014;40(2):110–3. Ivanovic N, Buche D, Fringer A. Voluntary stopping of eating and drinking at the end of life—a ‘systematic search and review’ giving insight into an option of hastening death in capacitated adults at the end of life. BMC Palliative Care 2014;13(1):1. Rady MY, Verheijde JL. Continuous deep sedation until death: palliation or physician-assisted death? Am J Hosp Palliat Care 2010;27(3):205–14. Royal College of Physicians. Prolonged disorders of consciousness: National clinical guidelines. London: RCP, 2013. http://www.rcplondon.ac.uk/sites/default/ files/prolonged_disorders_of_consciousness_ national_clinical_guidelines_0.pdf (accessed 23 May 2014). Institute of Medicine (IOM), National Academy of Sciences. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press, 2011. http://www.nap.edu/openbook.php?record_ id=13058 (accessed 23 May 2014). MacKintosh D. Death as “Harm” when it is an anticipated outcome in palliative care—or anywhere. J Palliat Med 2014;17(5):502. Chan RJ, Webster J. End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database Syst Rev 2013;11:CD008006. Montori VM, Brito J, Murad M. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA 2013;310 (23):2503–4.
Downloaded from http://jme.bmj.com/ on August 9, 2015 - Published by group.bmj.com
Liverpool Care Pathway: life-ending pathway or palliative care pathway? Mohamed Y Rady and Joseph L Verheijde J Med Ethics 2015 41: 644 originally published online July 18, 2014
doi: 10.1136/medethics-2014-102314 Updated information and services can be found at: http://jme.bmj.com/content/41/8/644
These include:
References Email alerting service
Topic Collections
This article cites 9 articles, 3 of which you can access for free at: http://jme.bmj.com/content/41/8/644#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections End of life decisions (ethics) (321) End of life decisions (geriatric medicine) (321) End of life decisions (palliative care) (321) Hospice (113) Pain (anaesthesia) (17) Pain (palliative care) (20) Assisted dying (191) Psychology and medicine (211)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
