“Hospital facilities are overcrowded, and long delays in securing treatment are universally noted”. Such was the observation of James Buchanan, economist and (future) Nobel Laureate in 1965. Over 40 years later the situation remains largely unchanged. Published in 2002, The Wanless Report was commissioned to study the failings of the NHS and served as the impetus for increased spending under then PM Tony Blair. It noted among key findings that the UK facilities were aged and in poor repair, that diffusion of new technology was lagging, and encouraged both increased funding and adoption of new protocols in treatment. As the American debate over health care reform grew over the summer, some prominent Brits weighed in in support of their national system. British PM Gordon Brown explained that “the NHS can mean the difference between life and death” for many subjects, while his wife merely added “We love the NHS”.

Since then, a flood of reports have confirmed Prime Minister Brown’s assertion, though not in the manner he intended. In August a British charity detailed what it termed the “appalling treatment” and “consistent pattern of shocking standards of care” submitted in case reports by the families of NHS patients.  Several days later this was compounded by a group of senior physicians and health care experts who wrote to express their concern over implementation of the “Liverpool Pathway”  a clinical stratagem designed to transfer the experience of Hospice to acute care hospitals.  In essence this pathway indicates a shift from management of illness to care and comfort in the terminal phase of life; a shift to comfort measures and withdrawal of active support.  In itself this is a reasonable goal- when used appropriately.  And of course herein lies the rub.  According to these experts rote implementation had led to a “tick-box approach to the management of death, causing a National crises in care”.  They detailed a Nationwide “wave of discontent” (traditional British understatement) as “family and friends witness the denial of fluids and food to patients. Syringe drivers are being used to give continuous terminal sedation, without regard to the fact that the diagnosis could be wrong”.

In a follow up article titled “Sentenced to Death on the NHS” the Daily Telegraph gives devastating insight into the problem.  Caregivers are directed to look for signs such as reduced levels of consciousness and difficulty swallowing medications, however, the consultant physicians note that many things could lead to such changes, including simple issues such as dehydration or the potent pain-killers administered to infirmed elderly patients.  Dr Hargreaves, a palliative care physician with 20 years experience states that “it is supposed to let people die with dignity but it can become a self-fulfilling prophecy”, adding that some patients were being “wrongly put on the pathway, which created a self-fulfilling prophecy that they would die”.  Noting that “tick box medicine that stops people thinking” he describes becoming more and more concerned about “this death pathway” coming into wide spread use.  Other contributing experts in the field lament  a “one size fits all approach” or note that “If they are sedated it is much harder to see that a patient is getting better”.  These seemingly obvious conclusions have somehow been overlooked in the NHS as clinical pathways and guidelines lead to withdrawal of medical care, withdrawal of food/fluids and  syringe pumps set to give “continuous terminal sedation” until patients expire.

As a final indictment of the system consider this fact:  in 2007-2008 16.5% of deaths in Britain came after continuous deep sedation, twice the number seen in Belgium and the Netherlands, counties where palliative care is well integrated into clinical practice.  Given the 574,000 UK deaths during this period, 47,000 fewer would be expected to have died under these circumstances if England had similar rates.  The obvious question is – how many of those would still be alive today without such cookie-cutter application of “end of life” pathways?

As shown in our earlier post, it can happen here as well.  I realize that the notion of death panels strikes many as preposterous and over the top.  Truly I doubt any intend such glaring lapses in care when designing what seems a reasonable goal: to minimize the misery and cost implicit in futile attempts to prolong life.  However, in application such ideas can indeed have grotesque results.  In the US,  medical spending per capita goes up steeply for the elderly, in the UK it does not.  While perhaps we Americans do err on the side of over-treatment, consider the contra-positive and decide for yourself how you feel these decisions should be made; by trusted physicians consulting with patients and family, or by integrated clinical pathways and medical panels whose self-fulfilling prophecies are beyond reproach?