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November 9, 2012 7:21 pm
Not long after learning how to prescribe drugs, I had to learn how to take them away again. After years focused on optimistic intervention, stopping was difficult. Drawing a line through someone’s tablets felt wrong: the first time I did it, I went to see the patient right afterwards, to check if anything had happened to them as a result of me crossing out their non-essential medication.
Mrs T was in a side room. Her feet stuck out of the bottom of her blanket in giant tiger-paw slippers. A fan flapped the cards on her bedstead; a collage of family photos surrounded a studio portrait of a ginger cat. She hadn’t eaten or drunk for two days; she’d last spoken three days earlier, when she’d asked the nurse to open the window. Now she was dying. Atorvastatin wasn’t going to help, nor was amlodipine, nor was aspirin, nor was metformin. Her high blood pressure was no longer an issue, her cholesterol level didn’t matter, and no one would ever need to nag her about her blood sugar again, or suggest she eat fewer Walnut Whips.
This is the situation that the Liverpool Care Pathway, used across England and currently the subject of government consultation, and similar palliative plans try to address. It is a tool for when you believe someone to be dying, a checklist to remind you of all the things you need to think about in order to let this happen peacefully and painlessly.
The LCP is a unique combination of evidence, kindness and paperwork which has recently attracted controversy for the same reason that palliative care always attracts controversy: caring for people who are dying gets conflated with trying to finish them off. But nowhere does the LCP suggest or sanction shortening life: its aim, as with hospice care, is to help people to live painlessly up until the very end. The LCP is there to help staff recognise that there is a point in someone’s life when trying to force a blood pressure tablet through their lips becomes cruel. It asks you to think about what your dying patient might need to help them feel better: to remedy symptoms, address fears, and consider the distress caused by thoughtless medical intervention.
I do not doubt that the LCP is misunderstood by families (often because we don’t explain it properly). It’s time-consuming for staff. There are also too many pages, all insisting that you do everything properly and document that you’ve done it. Have you thought about your patient’s spiritual needs? Have you talked to them about what’s happening? Have you written up all the drugs Mrs T might need in the future, so that if her breathing starts rattling, someone can treat her without a moment’s delay, even if it’s 4am? But used thoughtfully, it’s invaluable – as a prompt for what to think about in the muddle and sadness and anxiety of dying, and a guide for what not to forget.
The LCP does not insist you stop intravenous fluids or nutrition. No end-of-life pathway can tell you to do this: such decisions depend on the individual’s condition and needs. It does remind you to think about these issues – sometimes it may be kinder to stop a drip – but that is another topic. Nor is it an irreversible pathway to death: every junior doctor thrills to tales of patients who were “LCP-ed” and suddenly got better.
As Dame Cicely Saunders, founder of the hospice movement, said: “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.”
Sophie Harrison is a hospital doctor in South Yorkshire.
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