THE image of the Grim
Reaper might have been seen off with the old year, but the fear of
death is not so easily discarded; nor are arguments about how it
happens in hospital. The Liverpool Care Pathway (LCP), a protocol
for the care of dying patients, is once more in the news, partly
because of financial incentives given to hospitals nationwide as
they implement it.
Medical staff are, of
course, mortal (consultants excepted), and exposure to illness and
fatality does not make them immune from the normal anxieties about
death. Indeed, anecdotal evidence suggests that they might be more
susceptible as a result. This is coupled with a professional
objective of restoring every patient in their care to health. In
hospital, death is a failure. As a consequence, a gulf has
developed between hospital and hospice care - the latter being a
completely different, multidisciplinary approach that uses medicine
as just one part of the care. The LCP is a checklist for the last
three days of someone's care, as far as anyone can predict. It
prompts the team of clinicians, social workers, and chaplains to
consider carefully which actions and treatments (including
artificial nutrition and hydration) will allow the patient to die
with dignity, and which are futile or, worse, cruel.
No course of treatment is
prescribed. It is not "designed to finish people off double-quick",
as was reported by one middle-market tabloid newspaper that has
taken against the scheme. Patients are not "put on the LCP" by
doctors, so much as recognised to be dying and therefore better
served by the kind of questions the LCP asks of the team. The
decision that someone should be on the LCP is also reversible, as a
patient's condition can improve.
One of the key items on
the LCP checklist is communica-tion with the patient, if possible,
and with the family; and it is not surprising that this has been
the source of most diffi-culty. Counselling families, in a way that
enables them to hear and understand, calls for words that are not
always part of the clinician's lexicon, and doctors rarely have the
time to listen well. Behind many of the complaints about the LCP
can be found staff who are too busy, too stressed, or too
afraid.
The compassion that the Liverpool Care Pathway brings to
end-of-life care is to be welcomed; but compassion costs time, and
time, in the Health Service, costs money. It is asking much of NHS
hospital staff to develop the spiritual skills of unhurried
communication more often found in independent hospice care.
Hospitals would do well to draw on the spiritual resources of their
chaplains and of hospice workers, to enable their staff to face the
reality of death, and to try to help patients to die well.