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MPs’ report perpetuates failures of Liverpool Care Pathway, says senior doctor

Professor Patrick Pullicino

A senior Catholic hospital consultant has sharply criticised a report by MPs for seeking to perpetuate the “central flaw” of the discredited Liverpool Care Pathway (LCP).

The conclusions of on end-of-life care report by the House of Commons select committee for healthcare would allow the continued abuse of the elderly, terminally-ill and those suspected as suffering dementia, it was claimed.

Professor Patrick Pullicino, the first senior doctor to expose the failures of the LCP, said that practices proposed by the report might endanger the safety of patients placed on so-called electronic “death lists” by GPs because they would be denied an ambulance in emergencies if they had previously expressed a wish to die at home.

He also warned MPs that the report might accelerate often inaccurate “bedside” diagnoses of dementia among the elderly as a precursor to the denial of high-quality healthcare.

The health committee report was published yesterday as an attempt to establish an alternative to the LCP, which was abolished last July
following “shocking” abuse discovered in a review led by Baroness Neuberger.

Many families complained that their relatives were sedated with a “chemical cosh” then killed by the removal of food and fluids, leading Care Services Minister Norman Lamb to denounce the LCP as a “national disgrace”.

The new report called for greater patient choice as a solution with more to be done to allow people to die at home rather than in hospital.

Underpinning the proposals was the notion that patients use advance directives to plan ahead when their doctors suspected they will die within a year. But Professor Pullicino said it was not possible to know when a person will die and the claim to be able to predict the future was the defect that made the LCP so dangerous.

“This predication of a specific line of treatment on a prognostication of imminent death that is not evidence-based was the central flaw of the LCP and is perpetuated in this report,” said Professor Pullicino, a consultant neurologist with East Kent Universities NHS Foundation Trust.

Research into the question of how to diagnose imminent death accurately was “completely absent from the list” of priorities in the report, he said.

The doctor added that the safest solution would be to require NHS Trusts to notify the Care Quality Commission of “every instance of a patient not being given hydration for more than 48 hours or nutrition for more than a week”.

The emphasis in the report on end-of-life care for people diagnosed as demented was another area open to potential error, Professor Pullicino added, because it might mean their exclusion from hospitals where they lives might be saved.

Ambulances called to an emergency would read on an electronic register that such patients have opted to die at home and can refuse to take them to hospital.

“Dementia cannot be simply diagnosed by using a bedside screening test for cognitive function,” Professor Pullicino said.

“Dementia has to be a significant and permanent deterioration from a previous level of cognitive function.”

He continued: “The diagnosis of dementia is extremely variable and fraught with pitfalls and should not deny hospital treatment.”

The report was also criticised by Dr Tony Cole, chairman of the Medical Ethics Alliance, a group of medical organisations committed to upholding Hippocratic principles.

Dr Tony Cole
Dr Tony Cole

“There have always been difficulties in predicting imminent death and it is not possible to predict that death will take place within a year,” said Dr Cole, also a Catholic.

“My own wife was given a prognosis of three months to three years and lived for 20. Current research still shows that there is a 30 per cent major discrepancy between causes of death, as certified, and post mortem findings. Furthermore, a patient at the end of life may also have a treatable condition which could be relieved such as a bleed or obstructed breathing. People making their own end of life plan may not have foreseen this.”

The MPs’ report argues that most people who express a preference say they would like to die at home but this was made difficult by disparate
community palliative care services.

It said that 24-hour access to specialist palliative care in the community would greatly improve the way that people are treated.

Conversations need to be started with patients about their wishes so clinicians feel confident to address people they believe to be near the end of life, they said.

Sarah Wootton, chief executive of Dignity in Dying, the assisted suicide group, welcomed the report, saying it was important the people were able to plan ahead. She said choice at the end of life must be a priority for the next government, adding that the report’s recommendations should be implemented “without delay”.