Saturday, 11 October 2014

Liverpool Care Pathway - The Importance Of Remaining Zeke

The measure of the man is in his metal...
And its all about brass.

The Review

In order to circumvent the utter political embarrassment of criminal prosecutions, the Review - a review not into the LCP but into its operation - became a review into the operation of Version 12 LCP. The Review recommended the withdrawal of the LCP. What has happened?

Mr. Lamb got his wish reported in The Telegraph and...

Further reading -
Liverpool Care Pathway - "A Devil In Disguise..." 
...the LCP underwent a name change.

And the NHSLA (NHS Litigation Authority) announced a new £400m 11 Firm panel of legal eagles to indemnify DoH organisations including CCGs and independent NHS providers.

The Measures

ELCQuA, the End of Life Care Quality Assessment Tool, is a traffic light yardstick to appraise establishment and enablement of EoLC measures. It is an incentive tool to 'get out of the red' and get those measures up and running.

This is NICE Quality Statement 1: Identification - ELCQuA 

People approaching end of life are identified in timely way. 
101: People approaching the end of life are identified in a timely way. (NICE Quality Statement 1)
Identification of people approaching the end of life may be initiated by either health or social care professionals in any setting. Professionals should discuss the benefits of being identified and the use of a register, EPaCCS or equivalent system with the person and their families and carers. Staff must, however, exercise judgement about when and whether to initiate discussions about end of life care. In treatment and care towards the end of life: good practice in decision making, the General Medical Council defines approaching the end of life as when a person is likely to die within the next 12 months. This time frame provides a guide as to when people might be identified as approaching the end of life. For some conditions, the trajectory may require identification and subsequent planning to happen earlier. For other conditions, it may not be possible to identify people until nearer the time of death. Identification should take place with sufficient time to enable provision of high-quality end of life planning, care and support in accordance with the person's needs and preferences. Identification will need to be considered on an individual basis. Examples of available tools for assisting clinicians with timely identification of people approaching the end of life, include: 
  • Gold Standards Framework prognostic indicator guidance 
  • Supportive and Palliative Care Indicator tool from NHS Scotland;
  • Quick guide to identifying patients for supportive and palliative care from Macmillan Cancer Support.
The Panels

Ezekiel Emanuel, one-time adviser on health policy in the Obama White House, stood accused of being a ‘Deadly Doctor’. There were charges of ‘Death Panels’, even an American T4 Programme.

Accused of healthcare rationing by age and disability, Zeke rounded on these political pundits, insisting that he had been quoted out of context from an academic work.

Further reading –
Liverpool Care Pathway - A Utilitarian Pathway
However all that is or is not the case, Zeke has floated ideas and those ideas have become embedded in the collective psyche and have advanced an invidious trend.

Zeke has cultivated an environment for these ideas to thrive and come to pass. There are always consequences, always consequences.

Mr. Lamb knows the truth of it, as was reported in The Telegraph. According to Mr. Lamb, the elderly are bed-blockers who will be the ruin of the NHS.

He wants them signed up to EPPaCCS to accept downsized care so they are not admitted for treatment in the first place.

The truth of it is here -
The Telegraph
Charities said the statistics reflect a “collapse” in the system of care for too many pensioners, who were being parcelled out of wards to save the NHS money, then given little care at home, placing them at risk of falls and infections. 
More than 50,000 patients a year are admitted to hospital after suffering a hip fracture - one of the most common and serious medical problems for the elderly.
The new research found that the number of cases who are discharged, then readmitted as an emergency within weeks after their health worsens, has risen from 3,658 in 2001/2 to 6,810 in 2010/11 - a rise of 69 per cent. 
The rise comes as NHS hospitals increasingly send patients home sooner, in an effort to cut costs.
The study found the average length of stay for hip fracture patients has fallen by almost five days over the past decade.
The truth of it is that the elderly require more care, not less. Better care means better outcomes.

Hospitals need to improve care for “high risk” patients, such as the very old or those undergoing dangerous procedures like emergency bowel repairs, who account for 80 per cent of deaths.
Doctors concede that there is simply not the money to provide such a level of care for all patients.
Research led by Dr. Rupert Pearse blames a “one-size fits all” approach that is “ingrained” in the NHS.

He warned: “We’ve always known that we had a problem, but this study shows it’s more serious than previously thought. It’s very worrying and we need to act.”

The whole point of 'care' is that it is provided to those who need it and, by definition, those who most need it. This is not happening.

Instead, those who most need care, their families and carers, are being engaged in discussions in EoLC.

Mr. Lamb called them bed-blockers.

A prominent and well-respected medical ethicist has gone further.

Baroness Warnock has said that elderly people suffering from dementia are “wasting people’s lives” and “wasting the resources of the National Health Service” and should be allowed to die. These are the words of a well-respected commentator on medical ethics.

Lady Warnock’s comments were published in an interview with the magazine of the Church of Scotland, Life and Work, and have been condemned by dementia charities.

Zeke has come out against euthanasia.

The very policies he has espoused and promoted by floating them in his 'academic' article, however, have actually championed what has become a cause célèbre in so-called 'assisted dying'.

Jacques Attali, is a leading French intellectual and former President of the European Bank for reconstruction and development.

He has said, "As soon as he goes beyond 60-65 years of age man lives beyond his capacity to produce, and he costs society a lot of money...euthanasia will be one of the essential instruments of our future societies."

Martin Amis

Martin Amis says euthanasia is 'an evolutionary inevitability'

Martin Amis says the 'primitive' Christian notion of the 'sanctity of life' is holding back debate on assisted suicide

Some further reading -
Liverpool Care Pathway - The Good, The Bad, The Ugly And The Diabolical

Question: Should the disabled ever desire death…?

The Complete Life 

Zeke Emanuel has had his musings published in The Atlantic.

In the article, Zeke argues that to become incapacitated is not a desirable state of affairs...
…living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.
This is it, Zeke, you are saying it. You are saying that disability is not a desirable condition to experience; disability is a condition in which it may actually be desirable to desire death.

The article is actually an argument for and a vindication of his Complete Lives system as discussed in his 'academic' article. Zeke even includes a graph - a rip-off of his Complete Lives graph – which purports to demonstrate a theory of social usefulness which coincides with the prioritisation of medical intervention which the authors of the Communitarian world view favour.

Zeke says, quite blatently:
How do we want to be remembered by our children and grandchildren? We wish our children to remember us in our prime. Active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving. Not stooped and sluggish, forgetful and repetitive, constantly asking “What did she say?” We want to be remembered as independent, not experienced as burdens. 
At age 75 we reach that unique, albeit somewhat arbitrarily chosen, moment when we have lived a rich and complete life, and have hopefully imparted the right memories to our children.
This is pure Complete Lives, plain and simple.

Zeke has argued against euthanasia and assisted suicide, but
I have long argued that we should focus on giving all terminally ill people a good, compassionate death—not euthanasia or assisted suicide for a tiny minority.
By definition, old age is a terminal condition. Zeke has defined its onset in a statement of limitations:
I am talking about how long I want to live and the kind and amount of health care I will consent to after 75.
Zeke is talking about information standard EPaCCS, EoL preferences, rapid-discharge home-to-die pathways, signing up to death lists and ACPs.
Americans may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me.
Unequivocally, Zeke is saying that it is not a desirable outcome of old age to become incapacitated. Well, of course, it isn’t but Zeke is making a 'quality of life' judgement. This is an attack on disability.

The disabled still want their lives; they don't want a quality of life assumption made that they are better off dead.

The Plain Truth

The implication of what is being propounded here is clear and simple: it is healthcare rationing by age and disability!

This from the Local Government Information Unit -
Councils, with their new convening powers through the Health and Wellbeing Boards, are ideally placed to bring together health, social care and housing. Our report therefore calls for councils to take ownership of the end of life care agenda in order to enable people to spend their final days in dignity.
They will be using ELQuA -

And with a helping hand to help all this along with a £1m handout from the National Lottery Fund is pro-euthanasia 'charity' Compassion in Dying, which is now well and truly embedded in Age UK...

"I was delighted to meet the Project Co-ordinators from the other Age UKs at our first training event at Compassion in Dying’s headquarters in London last week. It was very encouraging to meet all the project staff in person, share ideas and to learn so much more about what we will be achieving through My Life My Decision. It’s such an exciting journey to be part of right from the beginning."
The groomers are being groomed at ‘training events’ in the CID HQ.

CID is a “separate legal entity” to DID, but they're still in cahoots...

This is Danielle Hamm, Director of this dodgy euthanasia charity that has hoodwinked Age UK into letting them share their toilet facilities, blogging on Dignity in Dying –

It is truly amazing what good marketing can achieve.

Pertinent reading –
Liverpool Care Pathway – Fur Das Wohl Des Staates

Liverpool Care Pathway - The Communitarian Nudge

Liverpool Care Pathway – The Grand Plan

Liverpool Care Pathway - It's Not the Crisis, It's What You Do With The Crisis

Liverpool Care Pathway - The Dust Has Settled. All Change! Nothing's Changed.

Liverpool Care Pathway - Murder On The NHS Express

Liverpool Care Pathway - The Communitarian Health Service Has Arrived

Sunday, 5 October 2014

Liverpool Care Pathway - A Scandalous Affair

To everything, there is a season and a time for every purpose under heaven. But it is not for us to determine or decide...

There are new life and death concepts being slipped in under the radar.

This is being sensible...
This is winding down our lives...
This is accepting and understanding the inevitability of death...

This is responsible decision making.

An elderly couple in Belgium fear they will not be able to fund their care in later years. Their three children will not have the means, apparently, and have sought out a 'Euthanasia Practitioner' to take their parent's lives from them.

Strange is it not that those who scrimped and scraped to make ends meet to clothe us and feed us as babes and bairns may not expect the same from us?

A 'Euthanasia Practitioner'...!

I suppose we might call this person an EoL Facilitator...?

Their attitude will be applauded by some. This is a responsible approach to life and death, after all.

Their lives have reached a defining moment and, adopting a realistic approach to dying, they are planning appropriately for the event. This is a 'healthy' approach to death.

This is recognition of the 'Complete Life'.

They are being supported by those closest to them. Their three children have gained them access to high quality care that will gently ease them from their mortal coil, devoid of prejudice in relation to their personal situation.

There was a time to live and, now that is done, they seek a 'quality' outcome; living and dying well, arrangements have been put in place in advance to prepare.

You have to be 'matter of fact' about these things.

We bystanders, we ask, 'How did we come to this; how did we get here...?'

 'A Time To Die'

 This is Simon Caldwell reporting in the Mail -

Cash-strapped councils are acting like robber barons to fund what has been accepted as the cornerstone of the ‘social contract’ of NHS care – to be cared for from ‘cradle to grave’.

Further essential reading -
Liverpool Care Pathway – Another 'National Scandal'

The State enters into a social contract with the people by accepting money in the form of compulsory deductions taken from income (salary/wages/profits) at source, along with employer's contributions. This is the National Insurance which funds benefits and healthcare.
Having demanded and accepted payment for a service - the provision of healthcare - the State, the government, the NHS or such body designated by State or government to oversee public healthcare, bound by moral duty (and by the laws pertaining to contract!) has a responsibility of continuing care it cannot deny nor fail to keep.
Money has been taken in payment of a service. The provider, therefore, has an obligation and responsibility to provide that service.
You have paid your dues - you have had no choice but to pay - and have worked hard all your lives to pay for your home and to provide for your family...

and then they make you pay for it by snatching it all back to take care of you!

On the same page of the Mail is the following story...

Then, they do 'take care' of you!

The LCP continued in name long after the Lamb promised to scrap it. Some were actually still using version 11!

Where it has ceased to be used, it persists under numerous guises purporting to be a 'personalised' plan but, in essence and in spirit, still the same LCP. At Wirral, they made no bones about it and simply changed the name.

In September, Nursing Times published a defence by Anthony Wrigley of this killing machine, pointing out that the Review was actually an investigation into its use and not of its integrity.Wrigley sees no issue with applying the LCP within the 'Gang of 21' Guidelines.

June saw the publication of these Guidelines in One Chance To Get It RightThis was the much vaunted, long-awaited Wee Bee Long Alliance Fudgeway of 'five priorities'.

On a roll, this past week, Nursing Times owned up to its continued use in a report by Jo Stephenson.

This is the lead line beneath the banner -
Clinicians are continuing to use the controversial Liverpool Care Pathway for end of life, despite a major review concluding it should be scrapped last year, Nursing Times has been told.
 The report continues... 

Anthony Wrigley, a senior lecturer at Keele University who specialises in medical ethics and palliative care, argued that the LCP was “probably the best guidance in the world”, having been developed over many years.
“I am aware that certain institutions have gone back to relying on it,” he told Nursing Times. He said health professionals using the LCP would be “understandably reluctant” to say so, due to its tarnished reputation.
The report quotes Helen Brewerton as saying that there was never any problem with the Pathway and that it was 'assassinated' by the media.

'Never a problem...'

Not even with the pre-version 12 which the Review, significantly, failed to review?

And they are still diagnosing dying...

This is NHS Wales –

"Together for Health - End of Life Delivery Plan" was published in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government's expectations of the NHS in Wales in delivering high quality end of life care, regardless of diagnosis, circumstance or place of residence in Wales.The Plan sets out clear ways in which the voice of the individual, supported by those closer to them, is heard and respected at the centre of the services they need.
The vision:
For our population we want:
  • People in Wales to have a healthy, realistic approach to dying, planning appropriately for the event
  • People dying in Wales to have access to high quality care wherever they live and die whatever their underlying disease or disability, devoid of any prejudice in relation to their personal situation
We will use the following indicators to measure success:
  • % of people dying in place of preference
  • % of people with palliative needs on a primary care practice Palliative Care Register six months prior to death
  • % of people who die in usual place of care
  • % of people in Wales who die intestate
These are new life concepts that are being slipped in under the radar.

Being sensible...
Winding down our lives...
The inevitability of death...

A 'healthy' approach to dying.

Stated aims are -
To live and die well and to improve outcomes between now and 2016.
Detect and identify patients early for palliative care.
Living and dying well and supporting 'quality' outcomes may preclude curative options where such outcomes are determined insufficiently qualitative.

"Really, do you want to live like that...?"

Falconer's EoL Euthanasia Bill is due for a reading in the House of Lords in November. This is a signal event. Now, we are come to this.

The focus is on 'quality' outcomes.

This is Heywood, Middleton and Rochdale Clinical Commissioning Group -

The absolute focus on treatment options which improve ‘quality’ outcomes is a ‘quality of life’ judgement of treatment outcome.

‘Healthier people better future’ may be seen in a totally different light in the context of fewer unhealthy people through non-pursuit of outcomes which lack ‘quality’ via palliative rather than curative options.

If the demand is outstripping the available resources, quite simply, you cut down the demand on those available resources...

The spending authority [NAO] said councils may increasingly have to consider “managing demand or reducing services”, The Telegraph
Read further here -
Liverpool Care Pathway - Crying Wolf

Yes, whether distinguished journalist...

- This is Wiltshire

or renowned musician...

Liverpool Echo
or the countless anons who have perished in this medical holocaust...

You may be sure you will be treated likewise, without fear of favour and ‘devoid of any prejudice’ in relation to your personal situation, for that is the Communitarian ethos.

The 'slippery slope' has an Hideous Strength that determines its path. This is no chance outcome but a growing and relentless pressure...

Liverpool Care Pathway - Still Chasing The Pathway

Wednesday, 24 September 2014

Liverpool Care Pathway - A Cry For Caution, A Voice For Valour

Again, into the mirror darkly do we peer and must put away our childish things...

For now we see through a glass, darkly...
1 Corinthians 13:12
This is the New York Times 
The country’s system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released on Wednesday.

The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, called for sweeping change.

“The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and a former United States comptroller general, who was a chairman of the panel. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly.”
The arguments are the same; the same economics underpinning the reasoning for those arguments are mirrored in the same perverse symmetry.

The National Panel was chaired by David M. Walker, the former US Comptroller General from 1998 to 2008. The Comptroller General is the top accountant and chief fiscal watchdog. According to Wikipedia, the
"Comptroller General shall investigate, at the seat of government or elsewhere, all matters relating to the receipt, disbursement, and application of public funds, and shall make to the President when requested by him, and to Congress... recommendations looking to greater economy or efficiency in public expenditures.”
Greater economy and efficiency...

Burke Balch, director of the Powell Center for Medical Ethics, said:
“The report’s emphasis on cost-slashing will intensify, rather than calm, the well-founded fears of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths.”
The National Panel, which sat for two years, was funded by an ‘anonymous’ donor. The price tag for these ponderances came to $1.5 million. That’s some wealthy, influential and anonymous donor.

Death on Delivery
“Patients don’t die in the manner they prefer,” Dr. Victor J. Dzau, the Institute of Medicine’s president, said at the briefing. “The time is now for our nation to develop a modernized end-of-life care system.”
Ask most anyone how they would prefer their time to be when it comes and they will say they would prefer to depart this mortal coil in their own home in their own bed with their own family and loved ones about them. That doesn't mean, in the memorable words of my ageing young-at-heart US cousin, they're thinking of checking out anytime soon or they would want the doc to give up on them.

How often does death announce its coming? May death be so readily and accurately predicted? It may if provided succour and assistance.

The National Panel said Medicare should
create financial incentives for health care providers to have continuing conversations with patients on advance care planning, possibly starting as early as major teenage milestones like getting a driver’s license or going to college.
EPACCS in the USA!
The panel said that simply completing advance directives could have limited value because checking boxes does not accommodate the wide range of choices that an increasingly diverse American population wants. It said the system should be comprehensive, with medical wishes communicated to all of a patient’s providers and with access to palliative care and other support available around the clock.
This is the NHS EPaCCS Economic Evaluation Report 

The National End of Life Care Programme asked the Whole Systems Partnership to undertake an economic evaluation of the implementation pilots for Electronic Palliative Care Co-ordination Systems (EPaCCS). Eight pilots were originally identified for this programme during 2009/10, with live implementation occurring during 2011. Since then other localities have begun to implement EPaCCS and a national data set has been defined. The roll out and other information about progress in implementing EPaCCS is described in “EPaCCS, Making the Case for Change”, NEoLCP (2012).

Using conservative estimates, with a baseline setup cost of just £21K, by year 4 there is a cumulative benefit in excess of £272K projected.
Conclusion: The economic case for EPaCCS has been considered and there is sufficient evidence, with appropriate context taken into account, for recurrent savings after four years to be over £100k pa and cumulative net benefit over 4 years of c.£270k for a population of 200,000 people. Alternative approaches to implementation as well as different starting points will have an impact on these figures as the variation in outputs within the evaluation group clearly demonstrates.

The New York Times article makes patient choice the crux of its argument.

Patient ‘choice’ is argued as a factor in the argument, but it is quite apparent that this is respected only where the goal of choice is to downsize care expectations.

This is the Liverpool Echo 

Read further -
Liverpool Care Pathway – A Compulsory Medical Procedure?
This is the New York Times 

DUNDEE, N.Y. — Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year. 
End-of-life planning remains controversial. After Sarah Palin’s “death panel” label killed efforts to include it in the Affordable Care Act in 2009, Medicare added it to a 2010 regulation, allowing the federal program to cover “voluntary advance care planning” in annual wellness visits. But bowing to political pressure, the Obama administration had Medicarerescind that portion of the regulation. In doing so, Medicare wrote that it had not considered the viewpoints of members of Congress and others who opposed it.

Politically, the issue was dead. But private insurers, often encouraged by doctors, began taking steps. 
“We are seeing more insurers who are reimbursing for these important conversations,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade association. The industry, which usually uses Medicare billing codes, had created its own code under a system that allows that if Medicare does not have one, and more insurance companies are using it or covering the discussions in other ways.

This year, for example, Blue Cross Blue Shield of Michigan began paying an average of $35 per conversation, face to face or by phone, conducted by doctors, nurses, social workers and others. And Cambia Health Solutions, which covers 2.2 million patients in Idaho, Oregon, Utah and Washington, started a program including end-of-life conversations and training in conducting them.
Incentive payments...

and another perverse symmetry -

Dundee is the home of Scotland's Dignity Care Pathway.

See -
Liverpool Care Pathway - On The Road To Dundee
Are psychometric tools to be adopted by their US counterparts to facilitate the 'conversations'?

This is NHS England 

NHS England has as its ‘vision’ a “modernised NHS – driven by a clinically led commissioning system” which “focuses absolutely on improving quality outcomes for patients”.

Take away the hocus pocus and the focus is clearly on only those treatment options which provide an outcome of sufficient ‘quality’ to justify the cost.

How often does death announce its coming? May death be so readily and accurately predicted? It may if provided succour and assistance.

The arguments are the same; the same economics underpinning the reasoning for those arguments are mirrored in the same perverse symmetry.

Read further here -
Liverpool Care Pathway – Communitarian Inevitabilities 
Liverpool Care Pathway – And The Temerity Of Arrogance 
Liverpool Care Pathway - The Bee Wee Tool
Macmillan are running a hard-hitting campaign.

Macmillan are trying to make good the bad publicity the Review has reflected upon them by criminal association. They are trying to make good by capitalising on the good reputation of the brand.

Macmillan were themselves promoters and practitioners of what has been called a "Toxic Brand" – the Liverpool Care Pathway. They were up to their eyeballs in complicity. They bear the same guilt. The Review iced over what was wrong. It wasn’t at all that the Death Pathway had been misinterpreted and misapplied; it was that it was applied at all.

They imposed the Death Pathway. Is there no penalty to be imposed?

Macmillan are running a hard-hitting campaign. It is almost as if the alarm buttons hit during the clamour of newspaper reports and the outcry of protest by the families and loved ones of the victims disgracefully dismissed as ‘anecdotal’ in Parliament and which finally prompted the infamous, insufficient and ineffectual Review had never happened.

They are not carrying on where they left off; they never ‘left off’.

What defence have they? Like Hitler’s henchmen, can they say they were following orders? They were following the directives of the protocol of treatment advised by the Pathway.

Death is unpredictable unless we make it predictable. And it was.

Make it so...

Be Macmillan.