Politics: The Liverpool Care Pathway and End of Life Care in the NHS

The Liverpool Care Pathway and End of Life Care in the NHS

The way in which the NHS and Hospice’s look after terminally ill patients has faced much criticism in recent months. In particular the Liverpool Care Pathway has been the main victim of the majority of this criticism being branded as “a license to kill” by the Daily Mirror and the tabloid press.

So what exactly is the Liverpool Care Pathway?

    The Liverpool Care Pathway is a framework for end of life care in the NHS. To be placed on the Liverpool Care Pathway the medical team of the dying patient, including a senior doctor, must recognise signs that a patient is close to death. If a decision is made to place the patient on the LCP, all medical treatments, which do not alleviate their suffering and are deemed no longer of benefit to the patient are withdrawn. This frequently involves the removal of I.V. drips, although patients are still encouraged to ingest food and water orally whilst on the pathway as this is considered nursing care rather than medical intervention. 

     The pathway aims to provide a form of hospice care inside a hospital environment to prevent unnecessary suffering in the patient’s final hours. It is estimated that around 130,000 patients who die in hospital per year are on the Liverpool Care Pathway, therefore making up around 29% of the total number of deaths inside hospitals each year. The medical profession’s view of the Liverpool Care Pathway is that it is an extension of one of the NHS’s key principles granting patients autonomy over their own care. However, recent failings in the use of the Care Pathway, most notably doctors failures to secure the necessary consent from patients needed to be placed on the Care Pathway warrants debate as to the appropriateness and the effectiveness of the supposed best practice and its use in the NHS.

     

Controversy

        The first major criticism of the LCP is that doctors have no objective, or 'tick box' way of determining death in a patient. As a result it seems counterintuitive to withhold a patients medication when they may have months or even years of life left ahead of them. However it is important to realise that sufferers of certain medical conditions experience similar trends in the decline of their function. Contrary to popular opinion death from cancer is relatively easy to predict due to the very sudden and rapid decline in a patients health. Similarly, the decline in a patients health from lung or cardiac failure, whilst occurring over up to 5 years also experience a fairly rapid decline with noticeable symptoms over just a few short months, although intermittent declines in health may result in some time in hospital. In contrast death from dementia or frailty is substantially more difficult to predict. For this reason patients are monitored prior to being placed onto the pathway and then monitored to an even greater extent afterwards in order to reduce the chance of an incorrect diagnosis. Patients should only be placed on the LCP when within one or two weeks of death.

       

      To be placed onto the Liverpool Care Pathway there is a moral obligation on the part of to doctors acquire the permission of the patient or of a competent family member. However, although doctors have a moral obligation to ask for permission, Marie Curie states that “the LCP is not a treatment but a framework for good practice, therefore, written consent is not required” but details that plans “SHOULD be discussed with the patient where possible and deemed appropriate and ALWAYS with the relative or carer”. However, it is estimated 65,000 patients a year are placed on the Liverpool Care Pathway without their consent being given. Such figures are shocking. However, many supporters of the LCP argue that it is not the failing of the concept behind the LCP in these matters but that of the hospital providing the care. In the words of the BMJ, in practice “the LCP can only be as effective as the clinicians who provide it”. 

    Sadly, the knock-on effect of the tabloid press’ rhetoric attacking the LCP has lead to a marked drop in the number of patients consenting to being placed on the LCP and has created a PR scandal in the NHS. This is despite evidence increasingly demonstrating that the hospice care which the LCP aims to provide, is superior to more traditional methods of end of life care. In the recent VOICES survey (the only current national survey performed) 96% of individuals experienced pain when dying. However, over 60% of patients in hospices found such pain completely relieved as opposed to only 33% in hospitals. 

    As a result of  public backlash against the LCP and following a six month independent review, the government has decided to phase out the LCP over the next 6-12 months. The LCP is to be replaced by"individualised care plans and condition specific guidance" under recommendation of the review panel. This is because although the review panel and numerous nursing and medical professional bodies acknowledge that the LCP can be used to provide a model of best practice too many patients have received poor care as a result of failings in the implementation of the Care Pathway.

-Adam

Science - DRACO (Medicine's Secret Weapon)

DRACO (Antiviral)

        Viruses have long been one of mankind's greatest enemies. Indeed, the battle between humans and viruses stretches back millennia to a time when even Egyptian pharaohs were not immune to the deadly smallpox. In more recent times the Spanish Flu outbreak in 1918 killed over 50 million people, dealing a more deadly blow to a crippled Europe than the First World War itself. Even the H1N1 virus, more commonly known as "swine flu" which reached pandemic proportions in 2009, is now often dismissed as a relatively insignificant event, despite killing over 17,000 people.


       However, scientists from M.I.T. in the past few years have begun laying the foundations for what is already being called a "Doomsday device" in the war against viruses. This "Doomsday device" is in the form of DRACO (Double-stranded RNA Activated Caspase Oligomerizer) a bioengineered microscopic superprotein which it is hoped will be able to eradicate a variety of viral diseases. Current Antivirals have a limited usefulness due to the fact they can only inhibit the growth of pathogenic virus rather than destroy it and are specific only to certain strains of viruses. Furthermore due to their genetic variability viruses of the ability to mutate rapidly, potentially rendering an previously effective antivirals ineffective against the new strain of virus. DRACO overcomes this as DRACO actually kills virus infected host cells. Through various studies we now know that DRACO has the potential to eradicate over 15 different viral infections inside mice including H1N1, the rhinovirus (common cold), dengue virus and the adenovirus.

     DRACO works by detecting double-stranded RNA (dsRNA) which is expressed in almost all viruses but not in healthy cells, making dsRNA the perfect marker. When viruses replicate by invading a host cell the convert the DNA of the host cell into an intermediary stage of dsRNA. When two or more DRACO proteins recognise this viral dsRNA they release the enzyme caspase which initiates apoptosis in the infected host cell. Apoptosis is the process the host cell undergoes to destroy the virus, essentially cellular suicide.



          In conclusion, DRACO has been shown to exhibit many of the qualities which make it worthy of its comparison to an antiviral equivalent of penicillin. However, further intensive testing needs to be done still to progress DRACO through the different stages of Health and Safety regulations before human trials may be carried out. Although this further extensive experimentation needs to be carried out many of the scientists working on the project believe DRACO will be available for public use within the next decade. If the hopes of the scientific community in regards to DRACO are realised we might finally gain a significant advantage against our viral enemies.

-Adam

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Science - Quadruple Helix

The Quadruple Helix

        Cambridge University Scientists have recently discovered quadruple helices made up of four strands of DNA intricately laced together. Although such a molecule has previously been produced in vitro under laboratory conditions the discovery of the molecule in cancerous cells is the first known example of a quadruple helix structure of DNA in naturally occurring human cells. The Quadruple Helix, scientifically called a G-Quadruplex, is most commonly found in regions of DNA rich in the nitrogenous base guanine. G-Quadruplexes occur in greatest abundance during the 's phase' of cell replication and are formed inside chromosomes and telomeres.

    

     The discovery of the G-Quadruplex is of keen interest to the field of oncology due to the fact the molecule has only been identified inside cancerous cells. This means the G-Quadruplex could potentially have a role in whether a cell becomes cancerous in the first place. 

More significantly, however, is the possibility of new treatments being developed which specifically target the G-Quadruplex without damaging healthy cells. For years the 'holy grail' of oncology is to find a characteristic specific to all cancer cells alone which would allow such characteristics to be targeted without damaging healthy cells, destroying the cancer. Indeed, Professor Shankar Balasubramanian of the University of Cambridge's Department of Chemistry has already detailed “...links between trapping the G-Quadruplexes with molecules and the ability to stop cells dividing” suggesting that the Quadruple Helix has a significant role in leading to the uncontrollable and rapid division of cells in cancer. 

Further research into the G-Quadruplex, therefore, could pave the way for more effective and more personalised cancer treatments in the near future. Many research scientists have already begun advocating the benefits of potential treatments to pharmaceutical companies in order to get the next generation of cancer treatments along the development pipeline.

-Adam

                                                                                                    

For more detailed information please have a look at this excellent New Scientist article:

http://www.newscientist.com/article/mg21729014.400-quadruple-helix-dna-discovered-in-human-cells.html

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