Catholic Medical Quarterly Volume 64(1) February 2014

Reports

2013 Annual Report of the Joint
Ethico-Medical Committee of the CMA

The most important ethical issue this year has been the response to the Neuberger Review of the Liverpool Care Pathway.

 

It is difficult to summarise all the recommendations made by the CMA and CU in submissions to the Neuberger Review. However, the main points were as follows and many were reflected in the Review:-

 

• Patient management should be holistic and should address the medical, psychological and spiritual needs of the patient.
• Palliative treatment should be evidence based wherever possible. Further research is clearly needed and should be compared to best available practice.
• The use of palliative care should be based on the patient’s needs rather than rely on prognosis which is at best a subjective judgement.
• The focus of palliative care should be the relief of symptoms and where possible restoration of mental and physical function
• Good communication with the patient is fundamental to all clinical practice.
• Discussion of the patient’s condition and treatment with relatives should not be a substitute for dealing with the patient directly. Communication with relatives and carers is especially important in the care of the dying. However, this should always be done in a timely manner and with the consent of the patient unless the patient lacks capacity.
• Consent to treatment is necessary in palliative care as in other fields of medicine and should always be sought in a timely fashion where the patient has capacity. As in any other field of medicine, consent should be sought from patients for the diagnosis and treatment of their condition throughout the patient journey. This is particularly true of palliative care where the needs and wishes of patients should be actively determined before the patient looses capacity as a result of the underlying condition or treatment.
• The responsibility for patient care normally rests with the Consultant or General Practitioner. The overall responsibility for palliative care should not rest with unsupervised junior doctors.
• Treatment plans should be endorsed by senior medical personnel who should be available for further help and advice as the patient’s condition changes.
• There should be regular audit of the care of the dying which takes into account medical treatment, nursing care, spiritual support and the concerns of relatives and carers
• Hydration and nutrition should not normally be withdrawn or withheld and never withdrawn or withheld with the intention and purpose of bringing about the death of the patient. This is both unethical and unlawful.
• Financial incentives for placing patients on the LCP ought to be withdrawn. However, there should be appropriate funding made available for training of healthcare professionals in palliative care.

The Neuberger Review of the Liverpool Care Pathway (LCP) was published on Monday 15th July. Lady Neuberger said that “Caring for the dying must never again be practised as a tick box exercise and each patient must be cared for according to their individual needs and preferences, with those of their relatives or carers being considered too." She went on to say that “"What we have also exposed in this review is a range of far wider, fundamental problems with care for the dying – a lack of care and compassion, unavailability of suitably trained staff, no access to proper palliative care advice outside of 9-5, Monday to Friday."

The Review made a number of recommendations. There is a need for more evidence based care and research into the care of the dying. This is a view endorsed by the recent study of the LCP in Italy reported in the Lancet which shows that there is no overall benefit to patients compared to current best practice. Financial incentives to use the pathway will be stopped and there should be better funding and provision for education and training in palliative care. The LCP should be replaced by personalised care plans and there should be greater involvement of patients with their families and carers in decision-making. The deliberate denial of fluids is unacceptable and unethical. Communication with patients and relatives should be improved. Senior clinicians should be responsible and accountable for individual patient care. Doctors and nurses should be held to account by their regulatory bodies.

The Review is both welcome and necessary if the trust and confidence of the public and patients is to be restored.

Dr Philip Howard
Chair JEMC