Last Thursday, All Saints Day, I sat down to write a blog about the Liverpool Care Pathway (LCP). Since I had last written on this topic there have been an alarming number of newspaper articles describing the sadness and anger of relatives when a dying family member has been put on this “pathway” without their knowledge or consent. The LCP grew out of the hospice movement and its original purpose was sound: not to make inappropriate medical interventions when a person was obviously dying and to alleviate any pain during this process. However, it seems that this good practice, now standard in most NHS hospitals, has been abused. There are too many stories of imminent death being diagnosed wrongly, food and water being withdrawn too soon and drugs being deliberately administered to induce speedy unconsciousness for a deep disquiet not to be felt by members of the public. Indeed, the widow of a man who chose to commit suicide in the Swiss clinic Dignitas has added fuel to this general concern; interviewed on the Today programme recently, she made it clear that not only is euthanasia a good thing but that, through the LCP, “it also happens over here, but quietly”.
Even more shocking than widespread fears that all over the country, with an increasing number of frail, sick, elderly people in hospital, the LCP is being used as a covert method of euthanasia, was the news, given headline coverage in the Telegraph, that “the majority of hospitals in England are being given financial rewards for placing terminally ill patients on a ‘pathway to death'”. According to the report, “almost two thirds of NHS trusts using the LCP have received payouts totalling millions of pounds for reaching targets related to its use”. It seems that in some case “trusts are given specific targets to ensure a set number of people who die in their hospital are on the pathway”. A consultant geriatrician was quoted as demanding that “there should be questions in Parliament as to who instigated this policy and the cash payments should be stopped. You can’t pay people to use a certain protocol that everybody knows to be lethal.”
As I wrote at the start of this blog, I had sat down to write it, with the righteous indignation of Melanie Phillips’s own article on the subject, when the phone rang. It was from my niece in Ireland, to tell me that my older brother, Johnny, who had been taken into hospital a few days earlier with what they thought was a problematic lung infection, was not responding to treatment; he was now in a very critical condition. I instantly dropped what I was doing and caught the next plane to Cork. I arrived late the same night. Early the next morning, All Souls Day, I went to the Bon Secours hospital where he was lying in the intensive care unit. There was my dear brother, only a year older than me, who had stayed with me only a fortnight before and with whom I shared so many memories of the past, now lying helpless and struggling to breathe, with an oxygen helmet on his head and surrounded by bleeping and flashing machines.
But he was also entirely conscious and completely at peace. The first thing he said to me, with a wry smile (he had been an army officer for 30 years and had always described himself as a “bluff soldier”), was: “I think courage and dignity are required right now”. The second was: “Do you remember Churchill’s last words?” I quoted them. We had both shared a great interest in Churchill’s life and I was always looking out for memorabilia relating to him to give to Johnny. I reminded him now that my best find had been a 1940s biscuit tin at our local waste disposal dump, decorated with key quotes from Churchill’s wartime speeches.
The third thing he said was: “A friar in sockless sandals came round earlier and, to use an old-fashioned word, he has shriven me.” He then told me the hymns he wanted at his funeral, the simple inscription for his grave – no mention of honours or rank – and the words for a memorial card. They were from St Thomas More and Johnny recalled his own father, to whom he had been very close, telling them to him: “Do thou pray for me and I will pray for thee, that we may meet merrily in heaven.” The word “merrily” particularly mattered to him. He always had a great, if sometimes mordant, sense of humour, and heaven had to be a merry place. When someone replaced a blanket over his feet so they wouldn’t be cold, he said with a characteristic smile: “Don’t worry, they will be the first to burn”.
These little conversations and remarks went on for most of the day. Johnny’s children never left his side. My brother and sister joined us. A palliative care doctor came by and gently indicated that his lung capacity was decreasing and that his oxygen levels were dropping. A nurse quietly and sensitively monitored the situation, explaining to us that they would only give him morphine when his breathing had clearly become very distressed. A young lay pastor came and prayed a decade of the Rosary with us. A huge plate of sandwiches materialised from nowhere in the relatives’ waiting room. The sockless friar (a Capuchin) came back with Communion, the nurse opened a small aperture in Johnny’s “helmet” and he received a fragment of the Host with great reverence and recollection. He called for a sip of cordial and managed to suck a tiny amount with a straw. He also had a spoonful of ice cream. He made it clear that he didn’t need any more food.
At 4pm he was asked if he would now like some morphine to ease his, by now, very laboured breathing. He said “yes” quite firmly. The doctor explained that the oxygen helmet was no longer of any use and it was gently removed. The machines were then unplugged and Johnny was made comfortable. He fell asleep. We all stayed with him, talked to him, sang to him, held his hands and stroked his head until, an hour later, he drew his last breath. My younger brother turned to me and said in a voice of awe, “What a mystery death is!” I thought of a favourite remark of Johnny’s, which he had repeated to me only a couple of hours before: “There are no pockets in a shroud.” The Capuchin returned and reminded us that All Souls Day was a wonderful day to die on. The palliative care nurse wept along with us all. I remembered that Johnny had chosen St Joseph, patron of a happy death, as his Confirmation saint and had always had a special love for him. In fact he had named a succession of his boyhood tortoises “Joseph” in the saint’s honour. In his last hours St Joseph had not deserted him.
I have described Johnny’s dying in this detail – and what a privilege it was to have witnessed such a death, his last loving legacy to his family – to show the kind of experience we would all wish for: sensitive and attentive care, spiritual and medical, by all the staff and the vital opportunity for Johnny to make his own inimitable farewells. It is a memory that his children and the rest of us will carry until our dying day. It presented a significant contrast to the sad, hasty and solitary deaths so many are subjected to, not least on the LCP. Johnny died, as he said, in the country he loved and surrounded by the people he loved; “My faith, my family and my friends are what matter to me,” he told us in his soldierly fashion. In the intensive care unit of the Bon Secours hospital, with its Catholic ethos and atmosphere – a crucifix on the wall and a statue of Our Lady in the corridor – patients are treated as children of God: “Johnny is in God’s hands,” the nurse said as she monitored him. It makes all the difference – in life and in death.
And Johnny’s own last words, before he slipped into unconsciousness? “I am very happy now.”
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