Friday, 2 November 2012

Liverpool Care Pathway – An Ageist Fallacy

These are extracts from 'A review from the literature' commissioned by the Department of Health and carried out by the Centre for Policy on Ageing -

Ageism and age discrimination in secondary healthcare in the United Kingdom
6.5.2. The perception is that older people form a high proportion of Accident and Emergency cases but in reality, over 65s make up 15‐18% of A&E admissions.(Downing and Wilson, 2005; British Geriatrics Society, 2008) However, in relation to the numbers of older people in the population the picture is very different. The attendance rate per 1,000 population is much higher for those aged 80 and over.

6.5.3. Individual, high profile examples of poor care in Accident and Emergency departments, particularly affecting older people and resulting in the deaths of patients, can and do occur. A 2009 Healthcare Commission report into the treatment of patients at Stafford Hospital between 2005 and 2008 found that 400 more people died than would be expected. The report found that unqualified receptionists carried out initial checks on patients arriving at the accident and emergency department, heart monitors were turned off in the emergency assessment unit because nurses did not know how to use them, there were not enough nurses to provide proper care, patients were "dumped" into a ward near A&E without nursing care so the four‐hour A&E waiting time could be met and there was often no experienced surgeon in the hospital during the night. (Healthcare Commission, 2009, Review)
Statistically, this demonstrates that
  • it is a fallacy that old people are in themselves a disproportionate drain on NHS resources.
  • in the nature of things, as frailty and vulnerability set in, a higher proportion of this age group, of themselves, make consequent demands on NHS resources.
  • the old are more vulnerable to examples of poor care.
  • QuAF (Quality assessment framework) tick-box assessments requiring that everything looks all right on paper (just like LCP!) even though in reality it isn't actually contrive the pressured and the unscrupulous to act in an unethical manner. QuAFs actually contrive solutions which are not necessarily solutions at all. Hence the creation of the Acute Admissions Unit, which did, however, overcome the "dumping" problem.
6.8.1. ‘Do not resuscitate’ (DNR), ‘do not attempt resuscitation’ (DNAR), ‘not for resuscitation’ (NFR), and ‘allow natural death’ (AND) instructions on patient notes have been a cause for concern by older people’s organisations with a suspicion that, because of ageist attitudes in the NHS, older people are more likely to receive such orders, based solely on their age. (Ebrahim, 2000, Opinion) There is also a suspicion that, once a DNR order has been imposed, it affects not just the decision about whether or not to use cardiopulmonary resuscitation but also the general level of care that a patient receives (Dangoor, 2001, Opinion)
6.8.2. Concern was such that resuscitation gained a particular mention in the National Service Framework for Older People. “Specific concerns have been raised about resuscitation policies, and whether older people are more likely to be denied cardiopulmonary resuscitation on the grounds of age alone. ... local resuscitation policies should be based on the guidelines issued by the BMA, RCN and Resuscitation Council, and should be regularly audited to prevent age discrimination.” (Department of Health, 2001, Policy document)
6.8.4. Joint guidance on resuscitation has been issued by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing which indicates that DNR orders should only be issued by senior medical staff and should not normally be issued without consulting the patient or their family. A 2005 study of 58 DNR cases found that while all orders were issued by senior medical staff, in only 10% of cases had the patient been consulted and the family were involved in only 36% of cases. In addition, only one third of patient notes indicated clearly whether the order applied only to cardiopulmonary resuscitation. (Harris and Linnane, 2005, Small survey)
  • imposition of a DNR order should be in consultation with patient and family.
  • imposition of a DNR order impacts on the quality of care which follows.
  • there is inexactitude in the keeping of notes.
Both LCP and DNR are imposed outside of guidelines that this should be done in full knowledge and with discussion with patient and family.

A decision to apply a DNR or place on LCP must have and does have consequences not immediately manifest or understood. This does create a particular mindset that will impact upon the direction of care. Attitudes are down-geared from active supportive care to, at best, maintenance, at worst, active enforcement of the direction of the directive.

When an old person, frail and fragile, falls ill, that does not mean they're at death's door; that just means they require that little bit extra care.

Defining someone as ‘dying’ defines also the type of ‘care’ they will receive. It will be a ‘care’ that pushes them along a path to an easy passing; it will not be a care that maintains them and supports them along what passage of life they have left. It will be the rule of pessimism rather than the rule of optimism which holds sway and that will direct decision-making.

Pessimism will rule, morbidity will cloud judgement and guide a reluctance to apply measures that might promote healing rather than ease dying.

The predictable certainty of the care pathway, evidenced to have been religiously adhered to, ensures that - whatever the perception may be or may have been - guidelines are demonstrated to have been followed and boxes have been ticked.

To come full circle, the DOH document agrees and more recent newspaper reports have concurred  that older patients are less likely than younger patients to be referred for costly treatments and surgical interventions. So, where lies the issue?

The issue lies in that our old ones are likely to be viewed - in the nicest possible way - as bed-blockers. The NHS Trusts must make savings and the old, the frail and fragile of mind or body, are an easy target.

Plan: Draw up your lists; identify your victims; prepare them, psychologically, to accept their number's up; and, how laudable, reward them with a home visit from a LCP nurse.

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