Liverpool Care Pathway – A 'One Size Fits All' Approach?

A “one-size fits all” approach is “ingrained” in the NHS.

Doctors say hospitals need to improve care for “high risk” patients, such as the very old.

Doctors concede that there is simply not the money to provide such a level of care for all patients.

Enter the Communitarian solution - the Liverpool Care Pathway...

The Telegraph has this report (emphases are mine throughout) -

Surgery death rate 'twice as high as thought'

Twice as many people die after surgery in NHS hospitals as previously thought, according to a new report that finds serious shortcomings in the way many patients are treated.

People at a high risk of dying from surgery were routinely not being told of the dangers, said doctors,
often because hospital staff were not identifying them properly.  Photo: GETTY

By Stephen Adams,  Medical Correspondent

7:00AM BST 21 Sep 2012

The overall chance of dying within two months of surgery is one in 28 (3.6 per cent), found the study published today (Fri) in The Lancet.

Dr Rupert Pearse, who led the research, described its findings as “very worrying” and said many patients were simply not getting the care they should. “We need to act,” he said.

People at a high risk of dying from surgery were routinely not being told of the dangers, said doctors, often because hospital staff were not identifying them properly.

Patients were also being sent back to general wards after surgery rather than critical care beds because of a “one-size fits all” approach that was “ingrained” in the NHS.

Dr Pearse, a reader in intensive care medicine at Barts and the London School of Medicine and Dentistry, said lessons needed to be learnt from cardiac surgery, where information on death rates was freely available and hospitals vied to be the best.

A previous report, published last December by the National Confidential Enquiry for Patient Outcome and Death (NCEPOD), found the chance of dying within 30 days of surgery was just one in 63 (1.6 per cent).

But Dr Pearse said the difference between the two figures could not simply be explained by more patients dying in the second month.

“The great majority of deaths happen in the first seven to 10 days after surgery.”

Dr Pearse, an intensive care specialist, designed both the NCEPOD and the Lancet study, but said the latter was “more robust” regarding mortality rates.

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 latest study examined 10,630 cases in British hospitals during one week in April 2011. These included both pre-planned and emergency operations, but excluded those not requiring an overnight stay, as well as cardiac, neurological, radiological or obstetric surgery.

Patients undergoing specialist surgery are treated differently, for example by dedicated teams on dedicated wards. Dr Pearse argued that meant they essentially received better care.

He said the mortality rate among adult cardiac patients was now less than two per cent - even though they tended to be older, have worse health, and require more dangerous surgery than average.

“If we did the types of things that we did in cardiac surgery, in all types of surgery, outcomes would improve.

“With most surgery, the only thing that’s different is the surgeon. But this ‘one size fits all’ approach to care isn’t really working for the overall surgical population.”

Cardiac patients are treated by specialist teams of surgeons and anaesthetists and cared for by specialist nurses on dedicated wards.

Dr Pearse also said outcomes for cardiac surgery had improved markedly since the mid 90s, partly due to changes triggered by the Bristol Royal Infirmary scandal. Between 1990 and 1995, 35 babies died in its cardiac unit and dozens more were brain damaged due to lack of staff, leadership, and scrutiny.

This led to cardiac units being constantly audited, with results now published online.

“I think the reason we see such amazing care and excellent outcomes with cardiac surgery, is that hospitals compete with each other,” he said.

“If they find that their hospital is below par, they want to improve it.”

Doctors concede that there is simply not the money to provide such a level of care for all patients.

But they say 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.

However, Dr George Findlay, main author of the NCEPOD report, said “poorly organised services” meant hospitals too often failed to identify these patients. This meant some went under the knife when their chances of survival were slim.

He continued: “Risk is very poorly stated to the patient: very few have a statement of risk on their consent forms.”

Patients also encountered serious problems after surgery, he said.

“There are a lot of high risk patients who are just sent back to a normal ward, where they don’t have an optimal chance of recovery,” he noted.

“That’s so ingrained, it’s happened in the NHS for so many years, that it’s an accepted thing.”

However, he said that for most patients, who were relatively well and fit, the chances of dying from surgery were very low.
 

Medicine is also an 'art' and predicting death is not a hard and fast 'science'.

Doctors take the lives of their patients in their hands, effectively, as would gods the lives of mere mortals.

But nothing is ever a foregone conclusion: doctors are not Gods; they cannot tell with certainty, and must work not with assumption or protocol, but with the situation and the individual.

The more care, the better the outcome. But care costs money. Far better a set of cost-effective protocols.

What is a life worth?

There are no 'untermenschen', but there are 'ubermenschen'.