BMP (Best Management Practice) is considered by some to describe the process of developing and following a standard way of doing things that multiple organizations can adapt and use locally. With proper processes, checks and testing, it is thought that a desired outcome can be delivered more effectively with fewer problems and unforeseen complications. In addition, a "best" practice can evolve to become better as improvements are discovered.
By such means has the
Liverpool Care Pathway (LCP) proliferated.
BMP works well in many different scenarios to provide industry best management solutions, in the manufacturing process for example. In a non-mechanistic field such as medical practice, this is not necessarily the case. A flexibility is required that a flow-chart response does not tolerate or provide.
The danger of processes and procedures are that they place the practitioner inside a box out of which it is not permitted to step. The protocols of the Pathway supercede all others and must be adhered to. The processes and procedures are there, however, not to safeguard the person on the delivery end of the service provision but solely for the benefit and protection of the provider.
If there is any ‘come back’ for whatever reason, any complaint or issue raised, the question is asked: “Did you follow procedure. . ?”
Thus, there is no prospect to gain fresh insight, to view the situation from a different perspective. Any intervention by family, relatives or friends – or the patient - will be prohibited. The Clinician’s opinion takes precedence and is final.
The patient becomes locked into the Pathway. There are no second thoughts.
In the case of 'living wills' patients lock themselves into the Pathway. Any intervention by family, relatives or friends will be prohibited. It may be that they may reach a stage at which they plea themselves for hydration to proceed, but all such pleas will go unheeded and, no doubt, be viewed as the delirium of morphine-assisted onset of death.
The patient is locked into the Pathway. There are no second thoughts.
Living Wills are also known as Advance Medical Directives. Living wills state your position on whether or not and under which circumstance you would wish to discontinue treatment. Living wills may also set out your preferences for organ donation.
The Department of Health
The DOH committed to investing 286 million pounds over the two years to 2011 to support implementation of this End-of-Life Care Strategy. That is 286 million pounds spent to assist people on their path to the next world while denying the necessary funding to keep them alive and well in this.
Whilst, as reports over many years confirm to be the case, the old and frail are neglected, starved and forced to suffer all manner of degrading abuse in their final years. If not a quality life, the DOH is determined, at least, to give them a ‘quality’ death!
Commissioning for Quality and Innovation (CQUIN)
The CQUIN payment framework enables commissioners to reward excellence by linking a proportion of healthcare providers' income to the achievement of local quality improvement goals. More radical implementation of LCP is one of these goals.
The pressure is on local-level Business Managers to meet expected performance levels in order to maintain central funding. In the case of living wills, there is the twofold pressure to satisfy the demand of organ donation.
If corners may be cut, they will be cut. With the processes and procedures of BMP, the Pathway protocols are becoming an all-purpose conveyer belt to the morgue.
Every patient is an individual and every patient is an individual case. Whatever ‘signs’ the LCP defines as being an indication of approaching and encroaching death, none of these ‘signs’ are so atypical that they can be excluded from any other cause. Once on the pathway, these other causes are excluded without consideration.
Myoclonic jerking is seen more frequently at the end of life, but its appearance can be related to at least 21 other medical conditions. Opioid-induced myoclonus is also not uncommon. Requiring a diagnosis of ‘dying’ such as that which LCP expects of the clinician is difficult, therefore, and fraught with peril.
The Case In Hand - A Re-examination
Liverpool Care Pathway requires that two of the following ‘signs’ are looked for -
- The patient is bed bound
- The patient is semi-comatose
- The patient is only able to take sips of fluid
- The patient is no longer able to take tablets
Well, lets see now…
- The patient was bed bound
Mum was confined in her bedroom for two weeks, a prisoner of the steep stairs which she could no longer negotiate. This came about only because the District Nurse had advised that she should not sleep downstairs in her easy chair. Both specialist nurses attendant on Thursday 19th July 2007 at her home agreed that the leg weakness was precisely a result of her two week’s confinement.
- The patient was semi-comatose
Mum was being plied with oral morphine which reduced her to a condition of a virtual vegetable. She had always expressed the determination never to have morphine as this was the manner in which her wrongly-diagnosed husband had been finished off many years ago. It is stated that she “clearly consented” to it, however, inferring that she was sufficiently alert and aware to make such a judgement to formulate an opinion. Mum was most certainly not sufficiently alert and aware in my opinion on that Friday 20th July.
In my presence, the nurse asked her if she would like some more morphine, offering it almost as if it were a treat. Mum was clearly confused, incoherent and in a state of semi-consciousness, barely aware of my presence even. When I queried the administration of the oral morphine, the nurse just looked askance, surprised almost, and said that she had already administered two doses to my mother. I had commented to this nurse that my mother was hardly in a condition of sufficient consciousness or alertness to make a judgement to reach a decision and that she was clearly attempting to influence her against what I know would have been her wishes. When I attempted to make some sort of rational contact with my mother myself, however, this nurse then accused me of trying to persuade her against her wishes!
Furthermore, mum’s hearing aid had been damaged. I found this to be hanging out of her ear with the tube pulled out and loose. This was on the Friday, the 20th July. When I commented upon this, the reply was that it must have happened on the journey to Caterham Dene, in the ambulance!
If that was the case, it must be asked why the hospital staff attending to my mother’s care had not noticed and already attempted to remedy the situation. The question of patient communication is, surely, of paramount importance. Doctors and nursing staff are reduced to a profound disadvantage if they are unable to communicate effectively with the patient. Perhaps they had noticed: the tube was loose and the hearing aid was hanging out of her ear! Was advantage taken of the situation to ply her with morphine?
The ambulance personnel were most particular, however, in her management and care and I am certain that, when I left my mother on the Thursday evening, her hearing aid was still in place. In any case, when I telephoned later that evening, the nurse informed me that mum had asked if I had gone home and was happy with the response that I had done so. That suggests that, at that time, the hearing aid was in place and functioning.
- The patient was only able to take sips of fluid
My mother, by the Saturday morning, had been reduced to the state of an unresponsive vegetable. On Thursday, she was off her food but functioning and able to feed herself; by the Saturday, she could not feed herself and was unable even to lift a beaker of orange juice to her lips. Morphine is noted for having such effects as sedation and producing extreme confusion, and particularly so in the elderly.
Mum had experienced annoying respiratory tract secretions (RTS) for some two years and more which her GPs had failed to treat adequately or at all. One doctor prescribed her a steroid nasal inhaler. This only succeeded in producing a severe reaction, a ‘banging’ in her head, accompanying dizziness and distress, and no relief whatsoever. Dr Crispin denied any possible connection of cause and effect, but it was later suggested by Dr Jesshop that it may have been the case that there had been a reaction to the steroid content of the inhaler. The British National Formulary requires doctors to report side-effects.
- The patient was no longer able to take tablets
Four out of four.