Friday, 30 November 2012

Liverpool Care Pathway – And The Temerity Of Arrogance


It really is true to say that the judgement call is always - If this one can be brought back from the brink...

is this one really worth saving?

This is The Telegraph - 

If the Liverpool Pathway had been around when my half-brother Lorenzo was diagnosed, he wouldn't have survived a week


By   Last updated: November 29th, 2012

Lorenzo Odone with his father









Having a friend who works as a consultant in a hospital is a bit like knowing someone who works in the kitchen of your favourite restaurant: they can tell you the sous-chef's been spitting in your soup. Thus, when I asked my friend the consultant about the Liverpool Pathway he told me the horrific truth: everyone involved on the medical side knows this is euthanasia by any other name. Medics are panicking about the number of elderly Britons entering hospitals. The demographics point to this being a longlived trend rather than temporary phenomenon: something had to be done.
Incredibly, today, we learn that even the very young who are very ill are pushed onto this "pathway". I cannot imagine any parent, reading the description of what happens to these babies, ever allowing their child to be placed on the Pathway. To do so would mean condemning them to waste away before your eyes, shrinking into nothingness as they are deprived of life-sustaining ingredients.
You don't need to have my friend's qualifications to know that withholding liquids and food from any human being is a cruel means to certain death. Doctors, nurses, technicians who remove those feeding tubes from elderly patients or very disabled young ones, are complicit in killing off those patients. The motive may not be cruelty, but a pragmatic approach to NHS rationing;  the end result however is the same.
The Liverpool Pathway prides itself on predicting, accurately, when the time is nigh. But death is not "certain", nor is its timing: when someone is ill or very disabled but adequately fed and watered, they may survive for years. I know this first-hand: doctors told my parents that my half-brother, affected by Adrenoleukodystrophy, would die within a year or two of his diagnosis. They were "certain" of this. Lorenzo lived to 30. Had the Liverpool Pathway existed then, he would have been pushed on it – and his life extinguished in a matter of weeks. This is what Jeremy Hunt, the Health Secretary means by the "contempt" in which the NHS holds us.

Liverpool Care Pathway – Communitarian Inevitabilities

You don't throw the fish stranded on the shore back into the water. That goes counter to all Communitarian thinking.

BBC News Norfolk reports - 

Cancer doctor Henry Mannings

banned from giving drugs

Dr Henry ManningsDr Henry Mannings set up Star Throwers three years ago to help people with just days to live

This is Streetlife.com -


Question mark over future of Norfolk cancer charity after complaint against founder

Wednesday, November 28, 2012
11:11 AM

A question mark has been raised about the future of a valued cancer support charity in
Dr Henry Mannings in his office at the Star Throwers cancer support charity in Wymondham.
Wymondham after an official complaint was made about its founder.


Dr Henry Mannings, formed Star Throwers at a former GP surgery in the town, three years ago to provide more support to cancer patients and their families.

However, the charity’s future is in doubt after a complaint was made about the NHS-registered doctor to the General Medical Council (GMC) surrounding his treatment of two patients.
An Interim Orders Panel (IOP) of the Medical Practitioners Tribunal Service (MPTS) placed conditions on Dr Mannings’ ability to practise at a hearing on Tuesday, whilst an investigation continues.
One of the 18 month-long conditions is that he must confine his prescribing to posts within the NHS and not prescribe any medications in private practice.
It comes after a consultant made an allegation that Dr Manning gave chemotherapy to two patients with terminal cancer without authorisation.
The treatments relate to Rachel Lane, 27, and Thelma Dowsett, 78, who both died last month. However, their families have praised the treatment received from Dr Mannings and Star Throwers and said his help had extended their loved ones’ lives.
Star Throwers, an independent advice, therapy, and drop-in centre in Melton Road, Wymondham, was established in late 2009 by Dr Mannings, who has worked for the Norfolk and Norwich University Hospital in Norwich and the James Paget Hospital.
Dr Mannings, an oncology specialist, established the charity in frustration at the lack of support for people living with cancer.
Families helped by Star Throwers are writing letters of support for Dr Mannings to the GMC.
Former patient Lester London, 90, of Wymondham, who he was diagnosed with the degenerative neurological condition ataxia six years ago, said he had no doubt that Dr Mannings had helped prolong his life. He added that he was “shocked” when he heard a complaint had been made against his former doctor
“He is a fantastic chap and I feel indebted to him and he has managed to keep me going. He is a real doctor and is able to talk to people and be sympathetic,” he said.
Dr Mannings has also been told that he must inform the GMC of any new posts in the medical profession and allow the GMC to exchange information with his employer or any contracting body for which he provides medical services.
A spokesman for the MPTS said the IOP has made no judgement on any allegations against the doctor. The IOP will review its conditions in six months.
Dr Mannings was unavailable for comment yesterday.

 We need to care for the person, even when caring is difficult, and not kill the person who is difficult to care for.
Alex Schadenberg
"After a heavy storm, a boy walked along the beach throwing the stranded starfish back into the sea. A man watching shouted, 
"there are too many of them - it won’t make any difference." 

As the boy threw another starfish back into the sea, he smiled and replied - 
"it made a difference to that one!""



WEDNESDAY, 28 NOVEMBER 2012



Star Throwers Statement regarding the Interim Orders Panel Hearing for Dr Henry Mannings on Tuesday 27th November 2012

We would like to make it fully clear we understand the purpose of the GMC Interim Orders Panel is to ensure patient safety, which we are in full agreement with.

Dr Mannings attended a GMC Interim Orders Panel hearing on Tuesday 27th November 2012, after which the GMC have concluded that there are no grounds for suspension. However, they have decided to restrict Dr Mannings' prescribing of medication to within NHS premises only.

Star Throwers charity will remain open as usual, with Dr Mannings continuing to offer advice and support to cancer patients and their families.

The restriction is based on the allegations of one oncology consultant at one hospital, and is despite the fact that the two patients mentioned in the allegations had significantly benefitted from the therapy they had received from Dr Mannings. At no time have there been complaints from any of Dr Mannings’ patients or their families.

The loss of prescribing ability at Star Throwers is a loss to many of the patients who have been given up on by their own oncologist.

It is important to note that the IOP's decision is based "on the interest of patient safety" and has no bearing regarding any findings of fact or the veracity of the allegations.

Although we are not allowed to discuss the details of the Interim Orders Panel's decision report, we find the decision made by the panel difficult to understand considering the overwhelming evidence produced in favour of Dr Mannings, particularly by experienced senior oncologists, a professor of oncology, nurses and pharmacists.

We hope that there will be a full public GMC hearing, whose purpose is to decide the veracity of the allegations, within the next 18 months so that the true facts of this case will become evident.

Dr Mannings would like to express how touched he is by the hundreds of letters written and phone calls in support of Dr Mannings and all the staff at Star Throwers.

Thursday, 29 November 2012

Liverpool Care Pathway - The Rationale Of Rationing


This is Communitarianism -

It's rationale is the rationing of finite medical resources according to strictly defined Communitarian principles.


Here is the Communitarian Complete Lives System treatment priority curve:

Govind Persad BS, Alan Wertheimer PhD and Ezekiel J Emanuel MD published this in The Lancet  (Principles for allocation of scarce medical interventions) in 2009.

It's all about whose life is and is not worth saving. Every procedure and protocol now operates, in practice, using a flowchart as a guide.You could almost run it through as a new software tool for medical professionals to utilise to determine level of treatment priority, even for GPs to select their 1%.

This redefines the physician’s duty. The duty is no longer to the patient but to what is considered the greater good. That is the Communitarian definition of health care.

The CQC has warned - 
"an ageing population and funding pressures from “reduced economic growth” meant care homes and hospitals faced more “challenging times” ahead."
Such a scenario fits implementation of a Communitarian Health Service.

This is the Telegraph -



Care Quality Commission: Elderly denied dignity and respect

Elderly patients are suffering “poor” and “unsafe” care as nursing homes and hospitals fail to treat them with basic respect, a watchdog has warned.

7:00AM GMT 23 Nov 2012


A growing number of pensioners with dementia are denied help to eat and drink, robbed of their privacy and treated “as if they were not there”, as care homes and hospitals struggle to cope, the Care Quality Commission said.
In a major report based on 13,000 inspections, the regulator warned that too many nurses and care home staff oversaw “a care culture in which the unacceptable becomes the norm”.
The growing pressures of staff shortages, poor training, and rising numbers of patients with complicated health conditions were compromising standards of care, it said.
The watchdog called on managers of nursing homes and hospitals to ensure that patients were treated as individuals and involved in decisions about their own lives.
However, the CQC warned that an ageing population and funding pressures from “reduced economic growth” meant care homes and hospitals faced more “challenging times” ahead.
Jeremy Hunt, the Health Secretary, said there must be “no hiding place” for “substandard” care services and promised a greater focus on patients’ experiences in future.
Charities working for the elderly said the “shocking” report was “a serious indictment” of the treatment older people received.
In its annual State of Care report, the CQC investigated whether the government’s “essential standards” were being met for the quality of care across the NHS, care homes, and dental surgeries in England.
There were “many examples” of care homes and hospitals that provided an “excellent” service to patients.
"But CQC’s inspectors also see examples of providers who struggle to cope and fail to deliver the quality of care that people have a right to expect. We will not leave this poor care unchallenged,” it said.
One in five nursing homes, one in seven hospitals and one in 10 residential care homes denied patients help with “the food and drink they need”, the report said.
“Given that this is so vital to good care – particularly for older people – this is a real concern,” the report said. A similar pattern was seen in NHS hospitals.
One in 10 NHS hospitals inspected during the last year failed to treat patients with dignity and respect, “including an obvious lack of privacy, call bells being out of reach, and staff speaking to patients in a condescending way”, the report said.
Among nursing homes, caring for patients with dementia who require more intensive support, 15 per cent failed to meet basic standards for “respectful and dignified care”.
These failings were often characterised by “care staff talking over the person as if they were not there; having things ‘done’ to them, rather than ‘with’ them; and getting people ready for bed at a time that suits the staff rather than the individual people being cared for”.
The vast majority of nursing homes, care homes and homecare agencies fell short of the minimum standards for giving their staff “proper training, supervision and development”. Many failed to manage residents' medicines properly and keep adequate records.
The CQC said some NHS hospitals have “struggled to make sure they had enough qualified and experienced staff on duty at all times” who were properly supervised and trained.
Wards are running with “high vacancy rates” and “staff being asked to do too many different roles at once”.
Independent hospitals, which have much more predictable workloads, performed much better in treating people with dignity and respect, as 98 per cent met the legal minimum standard.
Janet Morrison, chief executive of the charity Independent Age, said the report was “shocking and unacceptable”.
“It is deeply concerning that the CQC suggests that pressure on care services is increasing the risk of poor or unsafe care,” she said.
Michelle Mitchell, director of the charity Age UK, said ministers must ensure hospitals and care homes receive adequate funding because elderly care has been “stripped to the bone”.
“This report is a serious indictment of the way that older people are cared for in England,” she said.
The Health Secretary, Mr Hunt, said “much more” work would be needed to improve standards of care across England.
“Next year, we will be measuring and publishing the experiences that patients have in hospital,” he said. “Where there are problems we expect the CQC and other regulators to take swift action.”
Mike Farrar, chief executive of the NHS Confederation, urged more hospital staff to blow the whistle on poor quality care on their wards.
“It is extremely worrying that some organisations are still not getting the basics right every time,” he said. “It is every patient's fundamental right to be treated with dignity and respect, and that means more than just personal privacy.”

Liverpool Care Pathway - The Communitarian Health Service Has Arrived

This is Communitarianism -


THURSDAY, 19 JULY 2012

Liverpool Care Pathway - A Utilitarian Pathway


The Nuremberg Code emphasized the primacy of the informed, voluntary consent of the patient in governing physician behaviour.

The Nuremberg Code rejected the utilitarian argument that the few may be involuntarily sacrificed for the benefit of the many.

These precepts, carved in the moral stone of the Code and in the very fibre of what we know to be right and wrong are today being questioned and brought into ridicule.


This is Communitarianism -

"Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect. The death of a 20-year-old woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects.... Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.... It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies, and worse still when an adolescent does."

Here is the Communitarian Complete Lives System treatment priority curve:

Govind Persad BS, Alan Wertheimer PhD and Ezekiel J Emanuel MD published this in The Lancet ([PDF] Principles for allocation of scarce medical interventions) in 2009.

Basically, it's all about whose life is and is not worth saving. This redefines the physician’s duty. The duty is no longer to the patient but to what is considered the greater good. Hence, the Communitarian definition of health care.


MailOnline - news, sport, celebrity, science and health stories

Now sick babies go on death pathway: Doctor's haunting testimony reveals how children are put on end-of-life plan

    • Practice of withdrawing food and fluid by tube being used on young patients
    • Doctor admits starving and dehydrating ten babies to death in neonatal unit
    • Liverpool Care Pathway subject of independent inquiry ordered by ministers
    • Investigation, including child patients, will look at whether cash payments to hospitals to hit death pathway targets have influenced doctors' decisions

    Sick children are being discharged from NHS hospitals to die at home or in hospices on controversial ‘death pathways’.
    Until now, end of life regime the Liverpool Care Pathway was thought to have involved only elderly and terminally-ill adults.

    But the Mail can reveal the practice of withdrawing food and fluid by tube is being used on young patients as well as severely disabled newborn babies.

    Sick children and babies are being discharged from NHS hospitals to die at home or in hospices on controversial 'death pathways' (file photo)
    Sick children and babies are being discharged from NHS hospitals to die at home or in 
    hospices on controversial 'death pathways' (file photo)

    One doctor has admitted starving and dehydrating ten babies to death in the neonatal unit of one hospital alone. 

    Writing in a leading medical journal, the physician revealed the process can take an average of ten days during which a  baby becomes ‘smaller and shrunken’. 

    The LCP – on which 130,000 elderly and terminally-ill adult patients die each year – is now the subject of an independent inquiry ordered by ministers.

    The investigation, which will include child patients, will look at whether cash payments to hospitals to hit death pathway targets have influenced doctors’ decisions.

    Medical critics of the LCP insist it is impossible to say when a patient will die and as a result the LCP death becomes a self-fulfilling prophecy. They say it is a form of euthanasia, used to clear hospital beds and save the NHS money. 

    The practice of withdrawing food and fluid by tube is being used on young patients as well as severely disabled newborn babies
    The practice of withdrawing food and fluid by tube is being used on young patients as 
    well as severely disabled newborn babies

    The use of end of life care methods on disabled newborn babies was revealed in the doctors’ bible, the British Medical Journal. 

    Earlier this month, an un-named doctor wrote of the agony of watching the protracted deaths of babies. The doctor described one case of a baby born with ‘a lengthy list of unexpected congenital anomalies’, whose parents agreed to put it on the pathway.

    The doctor wrote: ‘They wish for their child to die quickly once the feeding and fluids are stopped. They wish for pneumonia. They wish for no suffering. They wish for no visible changes to their precious baby.

    According to a BMJ article, a doctor had presided over ten such deaths in just one hospital neonatal unit
    According to a BMJ article, a doctor had presided over ten such deaths in just one
     hospital neonatal unit

    ‘Their wishes, however, are not consistent with my experience. Survival is often much longer than most physicians think; reflecting on my previous patients, the median time from withdrawal of hydration to death was ten days.

    ‘Parents and care teams are unprepared for the sometimes severe changes that they will witness in the child’s physical appearance as severe dehydration ensues.

    The use of end of life care methods on disabled newborn babies was revealed in the doctors' bible, the British Medical Journal
    The use of end of life care methods on disabled newborn babies was revealed in the doctors' bible, the British Medical Journal
    ‘I know, as they cannot, the unique horror of witnessing a child become smaller and shrunken, as the only route out of a life that has become excruciating to the patient or to the parents who love their baby.’

    According to the BMJ article, the doctor involved had presided over ten such deaths in just one hospital neonatal unit.

    In a response to the article, Dr Laura de Rooy, a consultant neonatologist at St George’s Hospital NHS Trust in London writing on the BMJ website, said: ‘It is a huge supposition to think they do not feel hunger or thirst.’

    The LCP for children has been developed in the North West, where the LCP itself was pioneered in the 1990s. It involves the discharge to home or to a hospice of children who are given a document detailing their ‘end of life’ care.

    One seen by the Mail, called ‘Liverpool Pathway for the Dying Child’ is issued by the Royal Liverpool Children’s NHS Trust in conjunction with the flagship children’s hospital Alder Hey. It includes tick boxes, filled out by hospital doctors, on medicines, nutrients and fluids to be stopped.  
    The LCP was devised by the Marie Curie Palliative Care Institute in Liverpool for care of dying adult patients more than a decade ago. It has since been developed, with paediatric staff at Alder Hey Hospital, to cover children. Parents have to agree to their child going on the death pathway, often being told by doctors it is in the child’s ‘best interests’ because their survival is ‘futile’.

    Bernadette Lloyd, a hospice paediatric nurse, has written to the Cabinet Office and the Department of Health to criticise the use of death pathways for children.

    '‘I have also seen children die in terrible thirst because fluids are withdrawn from them until they die'

    She said: ‘The parents feel coerced, at a very traumatic time, into agreeing that this is correct for their child whom they are told by doctors has only has a few days to live. It is very difficult to predict death. I have seen a “reasonable” number of children recover after being taken off the pathway.

    ‘I have also seen children die in terrible thirst because fluids are withdrawn from them until they die.

    ‘I witnessed a 14 year-old boy with cancer die with his tongue stuck to the roof of his mouth when doctors refused to give him liquids by tube. His death was agonising for him, and for us nurses to watch. This is euthanasia by the backdoor.’

    Alder Hey, pictured, confirmed that children and babies are discharged for LCP end of life care 'after all possible reversible causes for the patient's condition are considered'
    Alder Hey, pictured, confirmed that children and babies are discharged for LCP end of 
    life care 'after all possible reversible causes for the patient's condition are considered'

    Alder Hey confirmed that children and babies are discharged for LCP end of life care ‘after all possible reversible causes for the patient’s condition are considered’.

    ‘There is a care pathway to enable a dying child to be supported by the local medical and nursing teams in the community, in line with the wishes of the child patients, where appropriate, and always their parents or carers.’ Alder Hey said children were not put on the LCP within the hospital itself.

    Teresa Lynch, of protest group Medical Ethics Alliance, said: ‘There are big questions to be answered about how our sick children are dying.’

    A Department of Health spokesman said: ‘End of life care for children must meet the highest professional and clinical standards, and the specific needs of children at the end of their life. 

    'Staff must always communicate with the patient and the patient’s family, and involve them in all aspects of decision making.’

    THEY WISH FOR THEIR BABY TO GO QUICKLY. BUT I KNOW, AS THEY CAN'T, THE UNIQUE HORROR OF WATCHING A CHILD SHRINK AND DIE

    Here is an abridged version of one doctor's anonymous testimony, published in the BMJ under the heading: 'How it feels to withdraw feeding from newborn babies'.

    The voice on the other end of the phone describes a newborn baby and a lengthy list of unexpected congenital anomalies. I have a growing sense of dread as I listen. 

    The parents want ‘nothing done’ because they feel that these anomalies are not consistent with a basic human experience. I know that once decisions are made, life support will be withdrawn. 

    Assuming this baby survives, we will be unable to give feed, and the parents will not want us to use artificial means to do so.

    Regrettably, my predictions are correct. I realise as I go to meet the parents that this will be the tenth child for whom I have cared after a decision has been made to forgo medically provided feeding. 

    A doctor has written a testimony published under the heading: 'How it feels to withdraw feeding from newborn babies'
    A doctor has written a testimony published under the heading: 'How it feels to withdraw feeding from newborn babies'
    The mother fidgets in her chair, unable to make eye contact. She dabs at angry tears, stricken. In a soft voice the father begins to tell me about their life, their other children, and their dashed hopes for this child. 

    He speculates that the list of proposed surgeries and treatments are unfair and will leave his baby facing a future too full of uncertainty.

    Like other parents in this predicament, they are now plagued with a terrible type of wishful thinking that they could never have imagined. They wish for their child to die quickly once the feeding and fluids are stopped. 

    They wish for pneumonia. They wish for no suffering. They wish for no visible changes to their precious baby. 

    Their wishes, however, are not consistent with my experience. Survival is often much longer than most physicians think; reflecting on my previous patients, the median time from withdrawal of hydration to death was ten days.

    Parents and care teams are unprepared for the sometimes severe changes that they will witness in the child’s physical appearance as severe dehydration ensues. 
    I try to make these matters clear from the outset so that these parents do not make a decision that they will come to regret. I try to prepare them for the coming collective agony that we will undoubtedly share, regardless of their certainty about their decision.
    I know, as they cannot, the unique horror of witnessing a child become smaller and shrunken, as the only route out of a life that has become excruciating to the patient or to the parents who love their baby. 

    I reflect on how sanitised this experience seems within the literature about making this decision. 
    As a doctor, I struggle with the emotional burden of accompanying the patient and his or her family through this experience, as much as with the philosophical details of it.

    'Survival is often much longer than most physicians think; reflecting on my previous patients, the median time from withdrawal of hydration to death was ten days'

    Debate at the front lines of healthcare about the morality of taking this decision has remained heated, regardless of what ethical and legal guidelines have to offer. 

    The parents come to feel that the disaster of their situation is intolerable; they can no longer bear witness to the slow demise of their child. 

    This increases the burden on the care-givers, without parents at the bedside to direct their child’s care. 
    Despite involvement from the clinical ethics and spiritual care services, the vacuum of direction leads to divisions within the care team.

    It is draining to be the most responsible physician. Everyone is looking to me to preside over and support this process. 
    I am honest with the nurse when I say it is getting more and more difficult to make my legs walk me on to this unit as the days elapse, that examining the baby is an indescribable mixture of compassion, revulsion, and pain.

    Some say withdrawing medically provided hydration and nutrition is akin to withdrawing any other form of life support. Maybe, but that is not how it feels. The one thing that helps me a little is the realisation that this process is necessarily difficult. It needs to be. 

    To acknowledge that a child’s prospects are so dire, so limited, that we will not or cannot provide artificial nutrition is self selecting for the rarity of the situations in which parents and care teams would ever consider it.


    This is Communitarianism -

    Emanuel believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those "who are irreversibly prevented from being or becoming participating citizens . . . " (Hastings Center Report, Nov.-Dec. '96).

    Savings, he writes, will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others" (Journal of the American Medical Association, June 18, 2008).

    We have seen even the likes of Dr. Christian Jessen tweeting thus -


    This is dangerous stuff. Who decides what is the greater good...?


    Why, the Great and the Good, of course! And who are they...?

    Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel, proposes a ‘complete lives system’ of healthcare.

    This is an extract from the paper he joint-authors with Govind Persad BS a and Alan Wertheimer PhD a, published in The Lancet –
    “Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on,' but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.”

    ‘Quality of life’ assessments are being made to determine who is treated and who is not.

    Those with learning disability, those mentally impaired in whatever manner or form, the old, infants, the vulnerable, are not being selected for treatment.
    These are the victims of “communitarianism” by omission.

    There are victims of “communitarianism” by commission, given DNR notices or slapped onto the LCP.

    The old and the disabled, by mental or by physical impairment, are at risk. But let us make it plain,- there are no untermenschen.

    That is not to say, however, that there are no ubermenschen.

    All menschen are equal, but some menschen are more equal than others.

    As my dear mum was wont to say in exasperation - "Wake up England!"

    This is the Communitarian Complete Lives System in action.

    Speak up, speak out, now. The Communitarian Health Service has arrived.

    Wednesday, 28 November 2012

    Liverpool Care Pathway – Anecdotes From The Wards

    The Surprise Question:
    ‘Would you be surprised if this patient were to die in the next few months, weeks, days’?
    It is all so prevalent in the press these days...

    The Telegraph reports upon yet another 'anecdotal' 
    story -


    Woman, 93, left severely dehydrated in hospital despite complaints from daughter

    A 93-year-old woman died after she was left severely dehydrated in hospital for hours despite complaints from her medical lecturer daughter, a hearing heard yesterday.

    A 93-year-old woman died after she was left severely dehydrated in hospital for hours despite complaints from her medical lecturer daughter, a hearing heard yesterday.
    Photo: ALAMY
    The elderly patient was taken to Pinderfields General Hospital in Wakefield, west Yorkshire, in “copious pain” after severe vomiting caused by a bowel blockage.
    But when her daughter, a University of Hull nursing lecturer, visited three days later she found her mother had not been connected to an intravenous drip to ensure she did not become dehydrated.
    A nurse “dismissed” her when she raised her concerns, a Nursing and Midwifery Council (NMC) hearing was told.
    Her mother died three days after the incident in May 2008.
    The council said the daughter’s complaints had been “brushed off” by the nurse, Erica Denton. When she returned later in the day, the drip had still not been connected. She “complained bitterly” and was overheard by a junior doctor but although the doctor and a colleague tried to help, they were unable to fix the drip adequately, meaning it was not connected until the night shift
    The daughter has refused to attend the hearing in protest after the NMC found other nurses on duty that day had no case to answer.
    Derek Zeitlin, for the NMC, said: “The patient’s daughter described how the registrant told her that her mother was fine when she was making an inquiry which really wasn’t by way of pleasantries.
    “Her concerns were dismissed and they really shouldn’t have been because her mother was suffering from a bowel blockage which had not been cleared for several days.
    “As a result of the patient’s health she needed to have fluids intravenously to keep her fluid levels up.”
    Mr Zeitlin described how the daughter had remonstrated with Ms Denton, adding: “At 11.00 that morning when the daughter arrived she noticed the intravenous infusion was not functioning, and she was concerned that her mother was becoming dehydrated with severe implications for her health.
    “She spoke to nurse Denton who claimed that she had spoken to the doctor.
    Later on in the afternoon she returned to the hospital and discovered the drip still had not been dealt with, and she complained bitterly and was overheard by a junior doctor.”
    The doctor attempted to fit the drip but knocked it out again as he left. Another doctor then tried to intervene but could not find a vein, leaving the patient, known only as Patient X, without fluids until the night shift. When a new team of nurses came on duty that evening, they quickly dealt with the issue, calling for a consultant to fit the drip.
    Denton was employed as a staff nurse by Mid Yorkshire Hospitals NHS Trust, and was working on Ward E of the hospital when the incident took place on May 5 2008.
    The patient died three days later, on May 8.
    Denton has admitted describing the patient as “fine” to her daughter, not requesting help from clinical support services and not ensuring medical staff fitting the intravenous cannula within a reasonable period of time.
    She also admitted not seeking the assistance of the "surgical bleep holder" to ensure the cannula was fitted in a reasonable time.
    But she denied failing to provide an adequate standard of care and misconduct that impaired her fitness to practise.
    The hearing continues.

    Liverpool Care Pathway – A Design For Death

    This is not a dole queue; it is a death queue...
    A Design for Death 
     Knowledge gives us power
    Aber arbeit macht frei 
    Just the silence of the Lamb; an eternal peace, not dignity  

    No good taking to the bottle
    That won't take away the hurt and the scars
    That show from where we came

    They don't talk about life, They raise the spectre of death
    No kiss it better, repair or mend
    As we are told that this is the end

    A design for death
    A design for death
    A design for death
    A design for death
    [Paraphrased from: "A Design for Life" - Manic Street Preachers]
    Once the mindset is set on this path, The Pathway is the only outcome.

    "People are ‘approaching the end of life’ when they are likely to die within the next 12 months." 

    The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’? 

    This 'challenge' question is not new. The St. Mungo workers have been 'challenging' themselves for some time! Now, it has wormed its way into the surgery. 

    Watch out, you old-uns, next time you're sat opposite the quack and he seems to be looking at you strangely, sizing you up perhaps, it might be for benefit of the undertaker! 

    This is from the GSF Prognostic Indicator Guidance - 



    The GSF Prognostic Indicator Guidance 
    The National GSF Centre’s guidance for clinicians to support earlier recognition of patients nearing the end of life
    Why is it important to identify people nearing the end of life?

    ‘Earlier identification of people nearing the end of their life and inclusion on the register leads to earlier planning and better co-ordinated care’
    (GSF National Primary Care Snapshot Audit 2010 )

    About 1% of the population die each year. Although some deaths are unexpected, many more in fact can be predicted. This is inherently difficult, but if we were better able to predict people in the final year of life, whatever their diagnosis, and include them on a register, there is good evidence that they are more likely to receive well-co-ordinated, high quality care.

    This updated fourth edition of the GSF Prognostic Indicator Guidance, supported by the RCGP, aims to help GPs, clinicians and other professionals in earlier identification of those adult patients nearing the end of their life who may need additional support. Once identified, they can be placed on a register such as the GP’s QOF / GSF palliative care, hospital flagging system or locality register. This in turn can trigger specific support, such clarifying their particular needs, offering advance care planning discussions prevention of crises admissions and pro-active support to ensure they ‘live well until they die’.

    Definition of End of Life Care
    General Medical Council, UK 2010
    People are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:
     Advanced, progressive, incurable conditions
     General frailty and co-existing conditions that mean they are expected to die within 12 months
     Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
     Life-threatening acute conditions caused by sudden catastrophic events.


    The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’?

    The same flow chart formula is employed -


    “Using the GSF ‘PIG’ has helped us to identify these patients earlier than we previously did, especially those with non-cancer, thereby giving them earlier support as they face the end of their lives, leading to fewer crises and hospital admissions.” (GP using Next Stage GSF Training Programme ‘Going for Gold’)


    ‘It is recommended that people approaching the end of life are identified in a timely way.’
    (Draft Recommendation NICE Guidance in End of Life Care 2001)


    “For many people suffering from a chronic illness, a point is reached where it is clear that the person will die from their condition. Despite this, for many conditions it may be difficult, if not impossible and potentially unhelpful, to estimate prognosis accurately. The Prognostic Indicator Guidance developed as part of the Gold Standards Framework (GSF) provides useful prompts or triggers to a healthcare professional that discussions about the end of life should be initiated, if this has not already happened”. (DH End of Life care Strategy 2008 England)

    Development of this guidance paper. This guidance was originally commissioned from the GSF Centre in June 2006 to support GPs include appropriate patients on their QOF Palliative Care Registers i.e. those considered to be in the final 12 months of life. It is regularly revised following extensive consultation with clinical and disease specialist groups, palliative care specialists and GPs in the Royal College of General Practitioners. Particular thanks go to the NHS End of Life Care Programme and University of Edinburgh team for their help. Since publication, this Guidance has been widely used by clinicians in many sectors in the UK and internationally. A list of detailed references is available on request. This is one of several tools available to support improvements in End of Life Care, and further details on best use, IT support and further developments can be obtained from the GSF Centre.

    The Gold Standards Framework Centre CIC info@gsfcentre.co.uk www.goldstandardsframework.org.uk 

    The document concludes - "This guidance was originally commissioned from the GSF Centre in June 2006 to support GPs include appropriate patients on their QOF." 

    Well, that explains a lot; that pre-dates by a year my mother's untimely demise at the hands of LCP nurses on the Pathway of which we were kept in blithe ignorance!