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.