Tuesday, 19 February 2013

Liverpool Care Pathway - The Morphine Overload

The LCP: One of its ten 'key messages' is that it 'neither hastens nor postpones death'.

This is the Advance Decision document which may be downloaded from Compassion in dying -

Page 3 of the document is a consent to treatment in certain regards -

I DO CONSENT TO the following treatment: (see guidance notes section 2).
(A) Any medical treatment to alleviate pain or distress aimed at my comfort. I 
maintain this request even in the event that it may shorten my life.

The guidance notes section 2 read -

Allows you to consent to pain relief, such as morphine, and treatment to make you more comfortable and alleviate any distress. If you tick the box at the end of section 2(A), you are giving permission for this treatment, even if it may shorten your life.
"even though it may shorten my life..."

Is there a similar clause in the consent form you sign before an operation? No, because when morphine is given following surgery, they put you on a breathing monitor to check respiration.

In modern anaesthesia, serious problems are uncommon. Risk cannotbe removed completely, but modern equipment, training and drugshave made it a much safer procedure in recent years.
Deaths caused by anaesthesia are very rare, and are usually caused by a combination of four or five complications together. There are probably about five deaths for every million anaesthetics in the UK.

Analgesics for more intense pain -
Stronger analgesics are often used in the first few days followingsome types of surgery. Pain is expected to be more intense then.Commonly used strong analgesics are morphine, diamorphine,oxycodone and fentanyl. These drugs may be given by infusion,injection or as patient controlled analgesia (PCA).

The risk associated with the anaesthetic is said to be 5/million. There is no associated risk mentioned in the regard of stronger analgesic use, such as morphine, as the intention to kill you isn't there, and no qualified anaesthetist would dream of giving you a combination of morphine and a CNS depressant without cardiac and respiratory monitoring.

"even though it may shorten my life..."

How may the same treatment be risk free for some NHS patients, but lethal for others? Is the only form of pain relief available one that also 'may shorten my life'? What is it that is being consented to? 

The LCP precludes 'unnecessarily burdensome tests'. The LCP, apparently, provides for review, but -

The Big Question -

Dr. Philip Howard –
"One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed."

No-one answered. There is no proper medical 'review'.

The 'Advance Decision' is made to provide for a moment of possible medical peril of apparent desperate proportion and is intended to provide for certain particular medical scenarios. Here, the nightmare thought of experiencing intense pain is being contemplated and a provision sought to manage that. If the 'Advance Decision' has come into effect, it must be assumed that this particular scenario is part only of a broader medical picture including other scenarios contemplated in the 'Advance Decision'.

The big questions -

Is the only form of pain relief available one which, automatically, risks killing you? 

In this 'Advance Decision', is consent actually being given for a morphine/sedative overdose?

Without proper medical monitoring (which is precluded) does the LCP, contrary to what is claimed, actually hasten death?

That being the case, in the situation of a wrong diagnosis of 'dying' being made, is not the subject of that diagnosis being placed in peril? Is not the LCP a perilous pathway? 

That being the case, in this 'Advance Decision', is consent being given to be placed on the Liverpool Care Pathway...?

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