Care of the Dying versus Care of the Living- What is the difference?
An NHS neurologist's perspective

It is important to remember that Care of the "Dying" is actually Care of patients who are "Still Living".

The reason to highlight this is that the diagnosis of someone being "In the dying process" is being made increasingly frequently in the NHS. The frequency of this diagnosis being made prior to someone's death has increased progressively from 8.5% of all deaths in 2004, 16.5% of deaths in 2007-8, 21% of deaths in 2008-2009 up to an estimated 29% of all NHS deaths 2011.(1)

I have two concerns:

1. Having so many patients diagnosed as "dying" in the NHS is adversely affecting care of the elderly.
When patients are diagnosed as "dying" they are often put on a pathway (The Liverpool Care Pathway) that limits certain medical treatments that are normally given to patients who are not diagnosed as "dying". I am concerned that care of all elderly patients is being affected by the fact that the NHS now has so many patients on this dying pathway. In many general medical and geriatric NHS wards there are now two classes of patient treatment: those receiving full active care and those having limited care on the dying pathway. This can be confusing to staff and has the danger of undermining the enthusiasm with which care is given to the elderly, particularly for patients who may be confused or uncooperative. I am concerned that this might partly explain the recently recorded decline in the nursing care of the elderly in our hospitals.

2. Seriously ill elderly patients who look like they are dying are being misdiagnosed as being "in the dying process" and are put onto the dying pathway.
This is a more worrying concern - that patients are being misdiagnosed as being "in the dying process" when in fact they are just very sick elderly patients. One of my patients was recently misdiagnosed as being in the dying process and put on the dying pathway. The patient very nearly was killed by the pathway, but made a full recovery when I discontinued the pathway and subsequently discharged him home.(2) Given the huge numbers of patients now being put on this pathway in the NHS, I am extremely concerned that there are many more patients who are being put on to the pathway inappropriately.

Recommendation: An ad hoc Parliamentary Committee should be set up to investigate the effects of the Liverpool Care Pathway on nursing care standards and mortality rates in the NHS.

Patrick Pullicino
Professor of Neuroscience, University of Kent
Visiting Professor of Neuroscience, St George's University of London

References:
1. National Care of the Dying Audit. Round 3 - click here
2. Pullicino, P. The Liverpool Care Pathway is dangerous and should be abandoned. Catholic Herald. Letter to the Editor. 7th May 2010.