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Normalising a homicidal culture of healthcare

The Liverpool Care Pathway had the unintended effect of turning death into a routine treatment so it is only right that it should be wound down, says Jacqueline Laing

19 July 2013

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The question of widespread neglect and passive euthanasia in hospitals, hospices and care homes has long been the subject of public and professional disquiet. For years, many of us have been warning of the lethal implications of institutionalising passive euthanasia and, in particular, sedation-dehydration regimes, as part of any national strategy especially in view of the catalogue of financial, political and research interests that there are in institutionalising homicide. The sick and elderly are costly and time-consuming, tissue and body parts are valuable, hospital beds, expensive, and cadavers all too useful.

The Neuberger Inquiry into the Liverpool Care Pathway was ordered following revelations by journalist Simon Caldwell in 2012. A moment of rational respite amid the clamour for state sanctioned medical killing, the recently published Report highlights widespread abuse of the vulnerable in institutions, the dangers inherent in current practice, and the need for an alternative approach.

Financial incentives

The Report on the Inquiry, unlike the response of substantial numbers of medical professionals who denounced all criticism, acknowledges what professionals and family members have been saying all along. The programme is lethal and the financially incentivised strategy invites that state of affairs. In particular, the editors at the British Medical Journal proved impervious to rational criticism, publishing overwhelming numbers of articles praising the questionable lethal regime. Given the gravity of the concerns, one might have expected greater impartiality.

What provoked the Inquiry? The Neuberger Review was a response to freedom of information requests to health trusts around the UK by Daily Mail journalists. The results were shocking. What emerged was a lethal engine in hospitals. The implementation of the Liverpool Care Pathway as the NHS National End of Life Care strategy in 2008 had been financially incentivised to the tune of millions of pounds. These financial incentives operated not by way of remuneration or personal reward to staff but by way of personal economic duress.

The figures demonstrated massive compliance in rolling out a deadly programme. Staff satisfaction earnestly reported in peer-reviewed journals with detailed accompanying statistics and specialised pie-charts, to those who could see what was happening in institutions or had simply understood the figures, was dangerously irrelevant. Some hospital trusts had been paid these funds for ensuring that up to two-thirds of all deaths were Pathway deaths. In the space of a few years, some health trusts had gone from 1 per cent of all deaths being Pathway deaths to around 70 per cent. There were reports of 130,000 people dying on the Pathway. It became clear that those faced with loss or curtailment of their livelihood would do what was necessary to retain it. And further, it seems, the Pathway was having a detrimental effect on professional attitudes to patient care.

Unforeseen side effect

The Liverpool Care Pathway is, we are assured, intended as a palliative care regime at the end of life. Even its critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. Critics of the Pathway are not committed to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. But asking whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. And this discrimination, it seems, typifies much professional patient care as the Neuberger Report outlines.

A key problem with the Pathway, however, and one still not addressed in any detail, is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient's capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical and legal professionals years ago.

Normalising homicide

If there are any lessons to be learned here they relate to the question of incentivising and normalising a homicidal culture of care. The report has recommended that all financial incentives are to cease and the programme is to be wound down. It highlights the need for professional care, communication and generosity to both patients and family members. It ill-behoves the medical profession, empowered as it is, to deride and disregard the sincere requests of family members for information about what is happening to loved ones. These tasks cannot be taken up by customer services representatives. They must be addressed by those privileged to treat and care for human individuals.

Academic journals must open their pages to legitimate dissent on matters as grave as homicide, and academic institutions should not stifle discussion where this is rational and evidence based.

There are significant implications to the normalisation of a death culture. The dangers of euthanasia regimes both active and passive are often overlooked in the competition to affirm and implement the apparently progressive. Vice, malice and reckless indifference to human life, however, are viral in character. Once entrenched they prove difficult to purge. The Neuberger Report highlights how it is that undermining professional attitudes to patient care leads inevitably to horrifying institutionalised human rights abuse.

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Vulnerable Clients