Back to the source: a response to Patrick Pullicino’s Liverpool Care Pathway paper

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Why do this?

This paper, published by Professor Patrick Pullicino in the Catholic Medical Quaterly (Volume 62(4) November 2012, online journal), represents the intellectual foundation on which the current, frequently destructive debate about the LCP is based. The research into prediction, prognostication, treatment withdrawal and misapplication formed the basis of a lecture at the Royal Society of Medicine in July 2012. This meeting was convened by the Medical Ethics Alliance.

As a general physician, gastroenterologist and hepatologist I have been and always will be involved in the care of dying patients. Although I am not a palliative care specialist, and although I do not have detailed knowledge of the evidence for or against the LCP, I do feel that I am qualified to make this response. For I am one of thousands of doctors who have been accused, implicitly, of practising euthanasia.

I have not attempted to submit this critique to the Catholic Medical Quarterly as correspondence.

In this article I summarise each of the paper’s section in turn and then present my own criticisms in italics. I have deliberately avoided trying to mount a full scale defence or overall justification for the LCP, choosing to limit myself to the points raised in Pullcino’s paper. Excellent articles extolling the LCP have been published elsewhere. It may be helpful to open the original paper in a separate window while reading this.

Introduction No comments.

Prediction and Prognostication The difference between these two terms is discussed. Prediction represents an individual clinician’s ‘educated guess’ of a patient’s expected survival, whereas prognostication is based on objective data and statistical modelling. It is emphasised that data does not exist to allow accurate prognostication in the ‘short term’, ie. the ‘final hours and days’ for which the LCP is designed.

Seeking to highlight prognostic scores that address patients with very short term survival prospects, he describes the Palliative Prognostic Score. This study split patients into three groups according to their estimated survival, median duration being 76, 32 and 14 days. 30 day survival probability for the latter group was 17%. He then mentions a nomogram (by Felieu J et al, 2011) which gives a 15 day survival probability, but points out that it was inaccurate a third of the time. ‘In this study, in a quartile (99 patients) of mean survival 10 days, over 10% survived much longer, with survival up to 200 days.’

These important observation force those of us who use the LCP to examine our thought processes. Are our prognostic/predictive skills really as bad as the literature would suggest? I know of no-one who uses prognostic scores and objective criteria on the ward. The diagnosis of ‘dying’ is indeed a subjective exercise, its accuracy increasing as patients display more and more typical clinical features. On further reflection however I concluded that the studies described are not particularly relevant to clinicians treating patients at the very end of their lives. What we are required to is recognise dying and manage it, not predict that dying will occur a week, two weeks or two months in the future. The question we must ask ourselves is ‘do we diagnose dying accurately?’, not ‘are we good at determining how long this currently stable patient will survive with this illness?’

Literature search The author states that no sources could be found to describe the use of prognostic scores within a ‘very early time frame’

No comments

Clinical factors associated with withdrawal of care This brief review concentrates on a study of organ support withdrawal in 15 intensive care units. It was found that subjective factors related to physicians’ perception of survival probability, potential cognitive deficit and substituted judgment of the patients’ view on resuscitation, but not age, prior functional status, illness severity or organ dysfunction were independently associated with the decision to withdraw. An accompanying editorial explored this phenomenon, raising concerns that physicians were ‘creating a self fulfilling prophecy’; ie. deciding that death was inevitable and facilitating it’s evolution.

The author then describes a study of patients with neurosurgical emergencies, reporting that survival was improved with aggressive surgical management and intensive care support. He concludes the section with ‘Practitioners tend to be overly pessimistic in prognosticating outcome based upon data available at the time of presentation.’

Although a discussion about the power of physicians’ opinions in end of life scenarios is valuable, and the danger of the ‘self fulfilling prophecy’ is of particular interest, I did not feel that studies of ICU patients were relevant to the LCP. The vast majority of patients put on the LCP do not have organ support withdrawn.

Care of a patient put on LCP A patient was admitted under the author’s care and put on the LCP by a trainee in the context of apparently intractable seizures. Next day the author determined that the relatives were not in agreement with it. LCP was withdrawn. The patient was discharged and survived for three months at home with maximal support for activities of daily living.

The error here appears to have been a lack of communication. The LCP was not applied correctly, and the author’s subsequent cancellation of it is not therefore surprising. The fact that the patient survived also demonstrates that the prediction, or prognostication, was inaccurate. My take on this case was that ‘intractable seizures’ is an unusual circumstance for the use of LCP, and the ‘diagnosis of dying’ all the more difficult. It is not surprising that the author was motivated to investigate the LCP following this experience. I wondered if the author’s experience of LCP in a non-medical specialty had led to a skewed view of its benefits and risks.

Conclusions The author states that there is no scientific evidence ‘to support a diagnosis that the patient is in the last hours or days of life.’ He then moves on to state that without an evidence base use of the LCP equates to an Assisted Death pathway. He highlights the very subjective decision making process, and recalls the problem of the self fulfilling prophecy.

The author then makes this hugely controversial statement: ‘If we accept to use the LCP we accept that euthanasia is part of the standard way of dying in the NHS. The LCP is now associated with nearly a third of NHS deaths. Very likely many elderly patients who could live substantially longer are being killed by the LCP including patients with “terminal” cancer, as the above research shows. Factors like pressure of beds and difficulty with nursing confused or difficult-to-manage elderly patients cannot be excluded as biases towards initiating the LCP.’

The full import of this statement is explored below, but even if the accusation of euthanasia is overlooked, it must be emphasised that no evidence has been provided to support an overall rise in mortality since the LCP was introduced.

Other statements include:

‘Starting a patient on the LCP, is an abandonment of evidence-based medicine in a critically-ill section of the hospital population’

Patients reaching the natural end of their lives are not critically ill.

‘Nursing of elderly patients who are on the LCP in proximity to those in whom evidence-based medicine is determining care, is confusing to junior medical staff and nurses alike’

Although deserving of attention, there is no evidence for this.

‘Use of the LCP is likely to have negative effects on elderly patients in particular, who are not on the LCP and to undermine the doctor-patient relationship’

This has certainly come to pass: trust between patients and doctors has been eroded during the LCP debate.

General critique

Defining prognosis and prediction is useful, although the difference between the two may seem rather semantic to many. As I have mentioned already, I am not sure that an analysis of our skill at prognostication is relevent to how we use LCP, the use of which is triggered by signs of possible dying. Nevertheless, if the LCP is perceived to guarantee death, it is very important that we identify dying patients accurately. Is this an achievable aim? Probably not. Should this admission result in abandonment of the LCP? Probably not. No methods of medical assessment, and no therapies, are 100% accurate or successful. As long as patients are reviewed regularly, to ensure comfort and to confirm the impression that the they are in fact dying, we should be able to minimise the risk of erroneous diagnosis while ensuring that the vast majority of patients benefit in terms of comfort.

It is the lack of evidence supporting the exercise of prognostication that drives this paper. The evidence that does exist in support of the benefit that patients derive from the LCP is not discussed. I think recognition that some evidence exists supporting the LCP would have added balance to this paper (for instance this ‘cluster trial’ – courtesy of Katherine Sleeman, Clinical Lecturer in palliative care, KCL, Cicely Saunders Institute).

Another area deserving discussion is that of communication. Prof Pullcino’s paper touches on this only briefly, during his description of the man with siezures, and I wonder if a greater focus on family conversations would have increased its relevance in this regard.

My overriding objection to this paper centres on the use of the word euthanasia. It is suggested that widespread use of the LCP equates to institutionalised euthanasia, and implicit in this is an accusation that individual practitioners have killed their patients. To read this, as a doctor who has used the LCP, is very difficult. The accusation is made in the conclusion without any supporting evidence. The ‘evidence’ that is reviewed in the paper does not touch upon intentional killing. If we are regularly making inaccurate predictions (or prognoses), that is of course unacceptable and must be addressed, but the term euthanasia suggests that we are intentionally killing our patients. There is absolutely no evidence for this.

This paper, and the thoughts behind it, sparked a huge controversy over end of life care in this country. I think it is methodologically weak and structurally flawed. I think it contains baseless conclusions, and is excessively liberal with emotive, hurtful accusations of intentional killing.

Acknowledgment: Dr Rita Pal alerted me to the paper’s online publication and has been helpful in researching details on the original RSM presentation.

 

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18 comments

  1. "As long as patients are reviewed regularly, to ensure comfort and to confirm the impression that the they are in fact dying, we should be able to minimise the risk of erroneous diagnosis while ensuring that the vast majority of patients benefit in terms of comfort."How do you personally ‘confirm the impression that the they are in fact dying’ when blood, urine and ABG tests have been withdrawn and cardiac defibrillators removed? …

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  2. What sort of signs do patients have that ‘confirm the impression that the they are in fact dying’ ….would be interested to know what signs you personally use…..

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  3. Particularly since you wrote"It is the lack of evidence supporting the exercise of prognostication that drives this paper. The evidence that does exist in support of the benefit that patients derive from the LCP is not discussed. I think recognition that some evidence exists supporting the LCP would have added balance to this paper (for instance this ???cluster trial??? – courtesy of Katherine Sleeman, Clinical Lecturer in palliative care, KCL, Cicely Saunders Institute)….how can this trial support the LCP in terms of benefit to a patient? It was designed to assess the quality of the LCP in terms of service delivery..nothing else – and only covers cancer care in Italy…do you have any more examples…??I bet the LCP would show massive improvements in service delivery in e.g. Kenya, or perhaps Pakistan..but its being operated in the UK..where patients are generally medically literate, and kinda thought Rusty Lee’s mother didn’t look that ‘terminally ill’ to them……

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  4. This is very well written Dr Berry. I would make the following points though 1. Multiple doctors have made allegations of the misuse of the LCP. Numerous patients with evidence based cases have made such allegations as well. In the face of such allegations, the medical profession cannot neglect their duty to ensure the LCP is better implemented. 2. There is an element of "defensive" writing in the above. You say that you like many doctors are being accused of euthanasia. This is a mistake in your comprehension. The fact is the public are alleging that "some" doctors "may" be misusing the LCP. 3. The paper by Professor Pullicino is by no means perfect. Then which paper is perfect. It does though point to a need for review of the LCP. 4. The most important potential conflict of the paper is the religious aspect. I am not certain why this was not discussed as it ought to have been. 5. You write "If we are regularly making inaccurate predictions (or prognoses), that is of course unacceptable and must be addressed, but the term euthanasia suggests that we are intentionally killing our patients. There is absolutely no evidence for this."Are you certain of this? If no one has done the studies on involuntary euthanasia, how do we know it is not widespread? You cannot state that " there is absolutely no evidence for this". You can merely state that we have not yet established evidence for this due to lack investigation. 6. You cannot deny that the media provides anecdotal evidence of potential LCP misuse. You cannot simply brush aside the public’s evidence as "invalid" because it has not been published in the BMJ or the Lancet or any other leading "medical journal". Please note, that the GMC regularly use the media reports as a basis to prosecute. 7. You implied on Twitter once that LCP was not evidence based medicine :). 8. You also fail to note that there are doctors who may well be discriminatory. Indeed, the reports Death by Indifference and other research point to this. Not everyone has the patient’s best interests at heart. If they did, the GMC would be out of business. It is clear, they are not as the complaints appear to be increasing exponentially.9. The only reason there has been an erosion in the doctor patient relationship is because the profession engages in a paternalistic approach. " Doctor does not know best" by the way. Good clinical care is based on listening to the patient. At present, the profession has adopted an antagonistic stance against vulnerable people who have suffered at the hands of doctors. This lack of sympathy or empathy is not going to achieve a net result. This defensive approach has not worked. In any event, the medical profession is now adopting an odd position of supporting comfortable deaths as opposed to addressing the concept that there may be misuse or abuse of the LCP. Euthanasia and involuntary euthanasia is unlawful. We currently have no idea how prevalent this is in the NHS. This is the point made by the public. Overall, I love debating this subject with you. Thankyou for your analysis of it. It was very useful. With Best Wishes. Dr Rita PalNHS Whistleblower on involuntary euthanasia :).

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  5. Yes, but he's decided not to post my requests for 'debate' – they were 'statistical'….but , his blog, his choice I guess:)<br><br><br>And as for the 'religious aspects' – the LCP is supposed to respect the spiritual needs' of the patient..as LCP version 12 contravenes catholic teaching…its USE, not only its ABuse (in that witholding of food and fluids is contrary to a Vatican ruling &lt;<a href="http://www.youtube.com/watch?v=okf88RnUHS8">http://www.youtube.com/watch?v=okf88RnUHS8</a>&gt;)?? Pius 12 on unecessary sedation …accelerating death contravenes the 5th Commandment…..<br> The only religious group I can find whose aim is to lay down in a darkened room and kill themselves by ceasing to eat, drink or move (!) are Jain aesthetes who wish to undergo 'Voluntary Death',: the Jain 'death modes' are?? <em>(1) Extreme Prudent's Death (Pandita-pandita Mara??a)<br> (2) Prudent's Death (Pandita Mara??a)<br>(3) Fool-Prudent's Death (B??la-pandita Mara??a)<br>(4) Fool's Death (B??la Mara??a)<br>(5) Extreme Fool's Death (B??la b??la Mara??a)&quot; <br>..which are expanded upon here</em> &lt;<a href="http://torontobuddhistethics.blogspot.co.uk/2010/08/jain-voluntary-death-as-model-for.html">http://torontobuddhistethics.blogspot.co.uk/2010/08/jain-voluntary-death-as-model-for.html</a>&gt; However, even this death is not 'respected' under the LCP, as the grieving relatives are supposed NOT to be near the dying patient as their grief causes 'disharmony'!!! <br> <br>This means that the LCP actively encourages ABuses?? of Jain patient's spiritual needs by allowing the relatives to even visit… <br><br>Ho hum 🙂

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  6. PS – failing to respect the voluntary death teachings of a Jain will apparently cause them to accumulate 'negative karma', which affects them deleteriously in their next incarnation…since this causes them 'pain and suffering', the size of an award for damages in a UK courtroom should reflect this, and any Jain put on the LCP without a consent form being signed should get massive damages … no longer a 'low quantum' job then!

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  7. 1. You write: "It is the lack of evidence supporting the exercise of prognostication that drives this paper. The evidence that does exist in support of the benefit that patients derive from the LCP is not discussed. I think recognition that some evidence exists supporting the LCP would have added balance to this paper (for instance this ???cluster trial??? – courtesy of Katherine Sleeman, Clinical Lecturer in palliative care, KCL, Cicely Saunders Institute)."This paper doesnt support any benefit to patients – it is a cluster trial of the roll out of the process….it automatically pre supposes patient’s benefit from being on this automated pathway for processing their death…

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  8. I think one of the main faults in the End of Life Care Pathway/Liverpool Care Pathway , which has ben responsible for its perception as a ‘Euthenasia’ Programme is the rather obscene lack of informed patient consent. Interpreted against the backdrop of the wholly specious ‘factoids’ that appear in the leaflets handed out to patients and their appointed decision makers/relatives (e.g. morphine is ‘not addictive’- what justifies lying to patients in this way?); relatives wonder what other lies they are being told, and one can’t blame them.Couple this to the fact that the ‘Just in Case’ boxes left with patients receiving care at home contain amounts of morphine and other drugs judged to be lethal in the Shipman trial, and indeed trialled in Belgium/Holland for euthenasia (rejected mainly due to the excessive time taken to death), with no requirement for a second witness to the destruction of unused drugs, and no adequate documentation or inspection of same, there is the possibility of unchecked abuse…the professional response should be to demand a Public Inquiry (with evidence given on oath, in public) , instead of which, Hunt has permitted those responsible for rolling out the LCP across the NHS (and to 22 other countries too) to ‘review themselves’…..which does nothing to restore faith in the medical profession at all.The only medical profession response to date seems to have been a ‘Go Petition’ organised by a House Officer (Natalie Silvey)….sadly it has done little to help…largely because of the insensitive way in which Tweets about ‘End of Life Care’ were interspersed with Tweets about cake making, book reviews and general infantile studenty chat about nights on the #iss! Despite being advertised in the Telegraph as a petition by the medical profession, it bore the signatures of medical professionals like ‘Howard Shipman’ and ‘J. Mengele’….do you wonder why the public have no interest in any practitioner’s perspectives on it?Should anyone else feel a Public Inquiry is required to restore public confidence in the medical profession, Hunt can be emailed using a DOH online form at :http://www.info.doh.gov.uk/contactus.nsf/memo?openform..use the subject line "Request for Public Inquiry into the Liverpool Care Pathway to restore public confidence in the NHS"

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  9. e.g. of ‘Anticipatory Prescribing’ :Diamorphine 10mg x 5 amps for pain or breathlessness??? Cyclizine 50mg x 5 amps or levomepromazine 25mg x 5 amps for nausea and vomiting??? Midazolam 10mg x 5 amps for agitation??? Hyoscine butylbromide (Buscopan) 20mg x 5 amps for respiratory secretions??? Water for injection as appropriate All prn doses too. really no safeguards to prevent a busy GP or district nurse thinking it was all required all at once really :)source: Somerset PCT : date issued 2008.

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  10. One must also criticize the medical profession for allowing this to be implemented in public wards in NHS hospital environments….if we assume an average ward contains 8 beds, every one of the 130,000 or so deaths involving slow starvation/dehydration/midazolam/morphine administration – could have been witnessed by 7 other NHS patients …I strongly believe they have rights too…perhaps your duty to them involves confining it to hospice wards where it belongs?

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  11. Astrid,1) No-one can say that diagnosing dying is scientific, and although clinical features have been described (see my previous post ???Missed opportunities: the diagnosis of dying and the risks of delay???) it still requires great experience. It does not requires blood tests, ABGs or heart monitors. The important question is, are we denying patients the chance to survive by making mistakes in that diagnosis? The relatives of patients who ???survived the LCP??? would argue that they were the lucky ones, while countless others have died unnecessarily. I seriously doubt this, because. LCP is started when patients continue to deteriorate despite treatment. By definition therefore, the treatment that is withdrawn cannot be ???life-saving???. It wasn???t working! The absence of IV fluids itself is very unlikely to tip the balance (personal view). Also, regular monitoring of the patient will ensure that any signs of improvement (eg. a delayed response to antibiotics, a state of delirium lifting) will be recognised, and the LCP will be reversed.Saying all that, if it cannot be guaranteed absolutely that mistakes are not happening, we must ask ourselves another question: is the overall good that the LCP does sufficient to outweigh the very rare instances of error? That is a hard question???2) What are the signs of dying that I personally use???It???s the whole sequence of events, the trajectory that the patient has taken before admission, during the first few days, their response to therapy???only after assessing these factors do the appearance and behaviour of the patient, at the time of deciding to initiate the LCP, become important. If, on a background of seemingly inexorable decline, despite active treatment, a patient stops eating and drinking, stops talking, cannot take their tablets???becomes unresponsive, those are the cardinal signs. The criteria for initiating the LCP include those changes.3) You make a good point about evidence. I did not provide a comprehensive list of citations. However, it???s not hard to find good evidence supporting the use of LCP, but not being a palliative care expert I chose not delve too deeply when others could do a better job.4) ReligionWhen strongly held religious views meets secular medical practice???there is bound to be a potential for controversy. However, I have never come across a situation in which use of the LCP has elicited complaints from the relatives of strongly religious patients. They have never said to me, ???She wouldn???t have wanted this, her religion forbids it.??? I think this is mainly due to the fact that kindness and caring underpin all religions, and these qualities are continuously demonstrated by ward staff when looking after the dying. There seems nothing irreligious about their attitude or approach.I look forward to meeting my first Jainist, and I hope they tell me what they want.Regarding Catholicism, there is some inconsistency. The Medical Ethics Alliance (to which Prof Pullicino belongs) disagrees with David Jones, director of the Oxford-based Anscombe Biothethics Centre, who was involved in the National LCP Reference Group [bit.ly/124w59T].Thanks for commenting Astrid! I wasn???t avoiding you, just couldn???t find the time earlier. Phil

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  12. Rita,1. Multiple doctors and patients???but still the tiny minority compared to those who have come out in support. I don???t know how we can prove how many ???satisfied??? families there are, relatives who sat with their loved ones as they died peacefully, protected against unnecessary investigations or futile, uncomfortable treatment. They don???t generally write to the Daily Mail.2. Defensive??? you bet! The LCP paper that I criticise, and the words that accompanied it at the RSM (I wasn???t there, but they were reported) appeared to suggest that euthanasia is widely practised???actually not even euthanasia, for that term suggests involuntary killing wholly for the good of the patient; financial and logistic benefits were alluded to. Anyone who has used the LCP is therefore included in this statement. That???s why I???m so het up!3. My papers are perfect Rita!4. Religion. Big, big can of worms. I???m winding myself up to get into this. It needs exploring, especially as the debate about Assisted Suicide is just about to re-ignite over the Falconer Bill. Watch this space. The essential point I would make though, is one of disclosure. We must be informed if a person???s, or group???s statement is motivated by religious concerns. If they are, then one could argue that those views can be largely disregarded if the patients to whom they refer do not hold to the same beliefs. 5. Good point, taken.6. Again, good point. But we also must bear in mind that the papers (in this case the Daily Mail and The Telegraph) are transparently biased. 7. Did I? You have a good memory. Also, I have learnt a lot through contact with experts who have a better grounding in the evidence base. My opinion may have changed about the evidence.8. I must admit that my comments about the benefits of the LCP are made with the assumption that those using it adhere to Good Medical Practise as defined by the GMC. Now, if the LCP being misused, that is not due to a problem with the LCP. Rather it is a problem with over-paternalistic doctors who are not communicating properly. They need correcting, obviously, and if they do not alter their behaviour the GMC should look into it. But it???s not a reason the ditch the LCP.9. I disagree – I don???t think that trust, overall, has been significantly eroded. Anyone reading the Daily Mail might suspect that it has, but on the shop floor, where individual patients meet individual doctors, relationships remain unsullied. You say, ???At present, the profession has adopted an antagonistic stance against vulnerable people who have suffered at the hands of doctors,??? but I have seen nothing of this. No medical groups or representatives have publically criticised those patients or families who have complained. And I believe the GMC is more active now than it ever has been, more willing to take up complaints and look into them. Thanks Rita, I???m sure we???ll be doing more of this in the future!Phil

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  13. Thanks for the reply: you say " it???s not hard to find good evidence supporting the use of LCP, but not being a palliative care expert I chose not delve too deeply when others could do a better job."IDelve a bit….you are using it…GPs are using it…I’d have to be convinced before I used anything…..there is no evidence base for any benefit to the patient, even according to the nurse practitioner who serves as the ‘medical director’ for the LCP. Dr Bee Wee admits so in: Wee B, Hadley G, Derry S.
    2008. How useful are systematic reviews for informing palliative care practice? Survey of 25 Cochrane systematic reviews. BMC Palliat Care, 7
    (1), pp. 13http://www.biomedcentral.com/1472-684X/7/13"ConclusionCochrane reviews in palliative care are well performed, but fail to provide good evidence for clinical practice because the primary studies are few in number, small, clinically heterogeneous, and of poor quality and external validity. They are useful in highlighting the weakness of the evidence base in palliative care. "The LCP is for terminally ill people….doses are off-license and ‘prn’…and therefore according to BNF standards, highly dangerous by definition. Bee Wee has herself blamed deaths on poor implementation of the LCP,and a lack of training….to recommend that untrained staff across the entire NHS to use ‘off licence’ dosages ‘prn’ …is unforgivably stupid, and arguably corporate manslaughter. As for ‘euthenasia ‘ being an illegal practice: if you look up ‘assisted suicide and euthenasia’ on ‘NHS Choices’ you will discover a statement of two things:1. that (as you point out) euthenasia is illegal, and 2. that the modes of euthenasia are a perfect description of the pharmacological effect of the drug regime used in the LCP.I think doctors in practice had better get used to the fact that euthenasia IS going to be legalised after Falconer’s amended assisted dying bill gets through next year…its going to have to be something they offer advice to patients on…and whatever statutory necessities are put in place, they will be treated with the same casual disregard and back clerking as all others.That will progress to the prison service (as it has in Belgium and Holland), and organ harvesting (as it has in China , Belgium and HollandI), and to ‘existential pain’ being justification for signing the paperwork to avoid human rights claims….I have (with some reservations) no objection to euthenasia, but every objection to doctors (who are, whether they accept it or not), complete strangers who we do not choose when referred to hospitals, making any choices whatsoever for me, or performing any action on me without my informed consent, unless the default assumption is very strongly in favour of preserving my life.

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  14. re: your point 8 to rita.Doctors using it are NOT subscribing to Good Medical Practice.-and if they are, GMC guidelines on Good Medical Practice needs to be changed.Jane Barton (Gosport War Memorial Hospital) – 120+ dead non terminally ill patients- was found guilty of dangerous prescribing by the GMC.Of the 7 sets of notes I’ve seen, the doses she administered were LOWER than those recommended by the LCP.As the LCP is now coded as ‘palliative care’ however, she could have prescribed 10 x higher doses, and would not even have been criticised.All it takes to find yourself on this care pathway is a ‘surprise question’….I’d like something far more rigorous than that..i.e. a patient’s consent!

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  15. PS: the use of morphine ‘prn’ for ‘breathlessness’ – recommended in the LCP, at the same time as withdrawing inhalers and O2……..that would surely be ‘dangerous prescribing ‘ at the GMC??? Certainly not in the best interests of any patient unless they wanted to die….

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  16. In the US, we have a history where we like to address Nazi Germany for the horrors it committed and yet, those same horrors were being committed in this country as well. People came out speaking about forced sterilization, inhumane medical experiments, people being locked away in asylums who were mentally fit… no one wanted to listen or dismissed the claims. Many of the claims were made by people like Professor Pullicino where those dismissing them focused more on protocol or who allowed a personal bias, such as what you admit to in regard to his use of the word “euthanasia”, to blind them. Then, the truth came out and we reacted to end such practices. However, we also acted to cover up that these things happened so that people today won’t believe you when you address these truths even when you go at great lengths to prove they happened. So, let’s assume for a moment that what the Professor says is true, even to a small degree, is the system not being abused and wouldn’t those being terminated early or who shouldn’t be terminated at all, euthanasia? While you may disagree with the term, if even 15% of what he says is true… how many thousands of people would that represent? Should this be dismissed just because of the good you view LCP does? And why would he praise a system when he’s trying to expose what could be thousands of deaths which are happening exactly as he claims? While I think you are being fair in many areas and you are not saying his claims are completely unfounded, I think you are ignoring the obvious that even if part of what he says is true, we’re not talking a dozen deaths or even a few hundred… we are talking a death toll in the thousands. Rather than just reviewing what he says, maybe you should investigate with an open mind to see if what he claims could be true. If you completely disagreed with him, I could accept your observations… but you seem to agree with many things he’s saying even where you say he doesn’t provide proof. That worries me not as a Brit (because I’m not), that worries me as a human being… doesn’t it worry you on that level?

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