Tuesday, 17 August 2010

The Liverpool Care Pathway

Today was one of the saddest days I've had, not only as a F1 doctor, but from starting out a fresh-faced medical student. Today, my team signed someone on to the Liverpool Care Pathway.

For those of you who don't know what it is, the Liverpool Care Pathway for the dying patient is an end of life protocol. For patient's whose death is expected an imminent, we withdraw all treatment other than medication to make the final few hours or days as pain free and comfortable as possible.

Now I've never been sure of the ethics of death. It's not something I've ever had to face in my professional career. Many people are heavily against the idea, some feel it "sanctions euthanasia", but seeing it in action as a doctor who is directly responsible for a patient's care really made me think twice about criticisms which I used to think may have an element of justification about them.

The hardest part is the deterioration.
Mrs Thompson (name changed of course) was one of those people who never let life's niggles bother her. About 6 months ago, she noticed some pain in her breast, but of course, didn't complain. It wasn't like her to do so. About a month later, she mentioned it to her son, who, naturally, was very concerned, and badgered her to see the doctor. She didn't. After another a month, her son made an appointment for her and dragged her to see her doctor.

Unfortunately, she had developed breast cancer. And unfortunately, this cancer had spread. There was little that could be done. She went home to spend time with her family.

A few weeks ago, she came in having lost six stone in only six weeks. She had completely stopped eating and drinking. One of the most important things in times like this are calories. The body needs sustenance to stay strong enough to go against the physiological effects that cancer has on the body. After treating her initial problems, she started eating again and things improved.

However, early last week, her appetite disappeared again. No matter what we did, how much her family encouraged her and no matter how often she was told how important it was to eat, she refused. She barely managed half a banana a day. Due to an underlying diagnosis of dementia and her advanced age, it was decided that PEG feeding (putting a tube through her abdomen directly into her stomach) was unfeasible. Immediately moves were made to try and get her home with a complete care package to look after her as best we could.

Unfortunately, these things take time. Over the last 48 hours, she deteriorated massively. On the ward round this morning, my consultant decided that if there was any further deterioration, she would be placed on the Liverpool Care Pathway. By late afternoon, she had become barely responsive and was bringing up secretions.

I phoned my registrar, who spoke to my consultant, who decided that there was nothing more medicine could do. I crossed out all her drugs and wrote her up for medication to take away the pain an nausea, whilst he spoke to the son about what was happening from here.

When you join medicine, you always have ideals of saving patient's lives and making a difference. The feeling you get when you have to simply admit failure is horrible. But it doesn't make a decision like this any easier. Death is an unfortunate consequence of being alive.

Withdrawing all other treatment may seem cruel, however, on reflection, it seems there is a time when everyone, including the junior doctor who's been at the bedside talking to the family and the patient for weeks, just has to let go.

When I go in tomorrow, I don't expect to see her name on the board.


Hypercryptical said...

A very sad story Dr Jr.
Death is inevitable at times and as you say, withdrawing treatment may seem cruel - but it is not.
When a patient ceases to eat and drink it is, at times, a sign that our body is preparing for death.
The Liverpool Care Pathway is a fine protocol that gives a holistic approach to the care of the dying.
Unfortunately I have found of late, that the LCP has been abused and misused. I wrote a post on same on August 7th. If you should read it - I would appreciate your comments.

Anna G.

Dr Jr said...

Thanks for your comment! I don't doubt this was a correct use of the LCP, but my doubts remain, especially after reading your post. I've left a comment.

Sadly she died about an hour after I left yesterday, so she had only been on the pathway for a few hours. One could argue we were nearly too slow to place her on it.

Hypercryptical said...

Thank you for reading my post Dr Jr

I am pleased - although that statement in itself worries me - that you share my reservations re the LCP.

Used appropriately - it (the LCP) is a fine wnderful thing and I am grateful that it exists.


Anna G.

The Dobbing Doctor said...

It's understandable to have such reservations about the LCP. I think it is a useful and holistic tool for the care of dying. Although some colleagues find it hard to admit that they could not "cure" the patient and are reluctant to use it.

A difficulty I've seen is if a patient has been on the LCP for more than 48hours. It leads to questioning of your diagnosis of dying and whether you should re-institute more aggressive management, and explain to relatives that things are moving slowly. Re-assessing the situation regularly helps.

Becca said...

Although it is very sad, and understandably not what you envisioned yourself doing as a doctor, please know that it is actually helpful and important.

When my mother-in-law died, I hugely appreciated the efforts of the doctors and nurses who helped keep her comfortable and the rest of us calmer than we would have been had she been suffering.

Dr Jr said...

Thanks to everyone for their comments. It really does help me get to grips with some of the less happy parts of the job.