Monday, 19 November 2012

Liverpool Care Pathway – An Hippocratic Oath An Hypocritic Expediency?

The Telegraph recently headlined –
Doctors defend Liverpool Care Pathway as 'dignified' way to die
The article reported on a petition raised by Dr Natalie Silvey and distributed on Twitter.

Some 1,300 Doctors, Nurses, Retina specialists, Clinical effectiveness facilitators, Chief immigration officers and Benefits advisers signed a letter in support of the LCP, a protocol applied to patients already diagnosed as being terminally ill and to those without such a diagnosis but diagnosed as 'dying'.

Some 1,300 signed the petition. Some 130,000 people die on the Liverpool Care pathway each year. Horrendous experiences have been reported. A few of these have been picked up and published by the Press.

The Telegraph blurs the truth in its headline. Dr. Silvey actually condemns the use of the LCP in practice. In her own words, "It is unacceptable."

The Liverpool Care Pathway surely stands in tatters.

The Telegraph recently headlined -
Liverpool Care Pathway: minister orders report into cash rewards
Government Ministers claim ignorance of The CQUIN payment system. These are our elected representatives charged with running their particular departments. Either Mr. Lamb was in ignorance or he is a liar. In either case, he should be removed from his position as an incompetent.

It has been public knowledge and has been reported in these pages -


The Department of Health (DOH) uses a Commissioning for Quality and Innovation (CQUIN) payment framework which enables commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals:
"It makes a small proportion of provider income (0.5% of contract value in 2009/10) conditional on achievement of locally agreed goals around quality improvement and innovation. It is intended that goals should be stretching but realistic."
CQUIN has set targets for 2011/2012 with regard to the End of Life program.

The forward plan is to increase the number of patients identified to be on the end of life care pathway and from a baseline of 0% to 20%; it is further planned to have 30% of all patients who die in hospital dying on the Liverpool Care Pathway.

To ensure they receive their provider income in fulll, Trusts have to comply with or exceed these goals. Some, like Royal Brompton, have upped the plan expectations:
1) 95% of patients identified as end of life (last 48 hours of life for expected deaths) are offered an EOL care planning discussion
2) 80% of patients offered a discussion should have an advanced care plan
3) 98% of patients who have an advanced care plan should have a record of the decision to resuscitate stated clearly in the notes
4) 50% of patients who die in hospital (expected deaths) should die on a Liverpool care pathway 
It is the DOH which is the driving force behind rolling out  LCP across the NHS!

From 'cradle to grave' was the promise. Cradle to grave has become a bit of a stretch with the pressure of the financial constraints involved. (It's that bit in-between that's the problem!)

Putting pressure on clinicians to identify patients as 'dying' to place them on LCP simply to achieve these DOH targets is fraught with peril! Clinicians will be hounded, against their better judgement, by cash-strapped Trust's business and finance managers to meet targets in order to sustain funding.

A 'high quality' life cannot be guaranteed but, by golly, they're going to make darned sure we all get a 'high quality' death!

A new national CQUIN goal has been introduced for use in 2012-13 -
An estimated 25% of acute beds are occupied by people with dementia. Their length of stay is longer than other people and they are often subject to delays on leaving hospital.
This particular goal is to help identify patients with dementia and other causes of cognitive impairment, alongside their other medical conditions and to prompt appropriate referral and follow up after they leave hospital.
For what purpose and to what end?

Answers on a postcard to -

Norman Lamb,
Minister of State at the Department of Health
79 Whitehall London SW1A 2NS

Or text - 020 7210 4850 

Any system of provision of financial payments or bonuses, supposedly, to 'reward' excellence is open to abuse. Look no further than the world of Banking. You're already being paid to do your job; just do it. 

What else is involved? What else could be involved? 

The imposition of a centrally approved program will be more readily rolled out with unthinking approval ratings when the financial heartstrings are plucked. It's a fast-track method of getting everyone on board singing unquestioningly from the same hymn sheet!

Those gifting, by right, summon obligation and compliance from the gifted. It is a tacit demand and expectation.

Dr. Christian Jessen tweeted his support for the "I Support The Liverpool Care Pathway" page on Facebook - 

"I support the Liverpool Care Pathway" would like to thank Doctor Christian Jessen for tweeting about this page (to his 160,000 followers). Much appreciated!
This is -
The Mission Message for this page is -
I support the APPROPRIATE USE of the Liverpool Care Pathway (LCP) for the Dying Patient. For the RIGHT patient, at the RIGHT time with CLEAR COMMUNICATION and TRANSPARENCY of what the pathway actually is - holistic assessment of a dying patient.
It is clear from the outset that the author of this statement acknowledges - from the language used and the use of upper case to provide emphasis - that grave and fatal errors have been committed. 

The owner of the page also makes the following telling comments -

REMEMBER: Whether pro or anti LCP, this all boils down to improving care and making sure people get the right type of care at the right time. 
Poor care of the dying is unacceptable. Poor or no communication with patient's, loved ones and even within healthcare teams are equally unacceptable. The Liverpool Care Pathway promotes good care but requires knowledgeable, caring and communicative staff. This is about making the last days of somebody's life as symptom free as possible with great nursing care and supporting loved ones through the trauma. There is one opportunity to get it right, especially for those left behind. 
REMEMBER: Behind every negative comment, there is a person, a story and a reason. It shows that people are PASSIONATE about making sure patients are cared for properly. 
I also know, for those that have joined this page, that I am "preaching to the converted". All we can say is that we support good care, we believe the LCP contributes towards this but we are under no illusion that more can ALWAYS be done.
Thank you for all of your contributions to this page and thank you for demonstrating that you really care.

Contributors to the page also appear to recognise and report failings. The site owner acknowledges these -

IMPORTANT MESSAGE - There have been a number of posts relating to the potential misuse of the Liverpool Care Pathway. These posts are very important and thank you for sharing them. I just wanted to remind people this page is supporting:

"the APPROPRIATE USE of the Liverpool Care Pathway (LCP) for the Dying Patient [in the last hours or days of life] and for the RIGHT patient, at the RIGHT time with CLEAR COMMUNICATION and TRANSPARENCY of what the pathway actually is - holistic assessment of a dying patient". It does not replace good clinician care and sound ethical decision-making. It does not say "stop everything" and it does not say "withdraw food and drink".

We believe this is a useful tool to promote best practice and have seen it help patients, families and carers. It helps doctors and nurses to focus efforts on providing the best care. We believe the LCP is part of the solution of ensuring good "end of life care", however, this is much more about people and how we interact.

For those who experienced poor care - this is why the LCP was developed. A document should not be scraped when its intention is to improve care and for many it has. The LCP is on version 12 and should continue to be improved and updated.

No doctor or nurse wants to do a bad job.
No one wants to see people die in pain.
No member of staff wants to be considered uncaring.
No family member wants to be ignored and
No patient wants to feel unheard.

It's time to work together people.
This is all very grand. These are bold statements to espouse. May we expect these Great and Mighty to press for the stiffest of measures to be taken against the so-called health professionals who have perpetrated these foulest of deeds in the name of the Liverpool Care Pathway  and brought it into such disrepute? May we hear these Great and Mighty calling for these, their colleagues, to be brought to book?

Dr. Christian Jessen tweeted -

Even so, even he might wish that those who have done harm should be brought to account and stripped of their medical credentials. Dear Dr. Christian, may you add your extolled and respected name to this cry from the wilderness for justice for our loved ones?

The new Facebook page speaks of 
"holistic assessment of a dying patient."
This, we must assume, means that the signs and portents have been duly read and the patient has been determined to be dying - that is, a diagnosis of 'dying' has been made and the appropriate LCP pre-emptive medicines have been prescribed. However...

What if that decision is wrong?

It is said that the Pathway is 'reversible'. It cannot be argued, though, that the effect of the trauma of applying the Pathway is reversible. These measures applied to a fit and able person might be an ordeal; to an unwell person, frail and fragile, the effect may well be devastating, perhaps fatal.

Might there be a case that the patient is not actually 'dying'? Might their frail condition even nullify any 'signs' that would indicate an improvement and, otherwise, mark them for removal from the LCP?

According to Dr. Sophie Harrison writing in the Financial Times, the patient is “LCP-ed” when you “believe” them to be dying. 'Belief' is not a sure enough parameter to use, however, if attempting to ‘diagnose’ dying.

An illness trajectory may follow any number of outcomes, but 'dying' leads only to one event horizon - death. Finality. And certain knowledge is impossible.

I have often seen this happen; patients you are convinced will follow a clear, definable illness-trajectory prove you wrong. It's this unpredictability that makes medicine so fascinating; the fact that the body has a remarkable capacity to confound expectations. Even for those with a terminal illness, there can be no certainties.
This is from The State Journal Register -

Medical misdiagnoses can have fatal consequences

Errors not rare

Medical errors are far from rare, according to several comprehensive studies of the issue.

But diagnostic errors - a subset of the overall problem - haven't received nearly as much attention as other medical errors since the nationwide patient-safety movement began in 1999 with the publication of the landmark Institute of Medicine report, "To Err is Human."

"Diagnostic error is barely on anybody's radar screen," said Dr. Mark Graber, 62, a nephrologist in Long IslandN.Y., and an expert on diagnostic errors.

The "To Err" report estimated that at least 44,000 and as many as 98,000 Americans die each year from all types of medical errors. More recent studies indicate there has been little progress since 1999, with as many as one in three or one in four hospitalized patients being harmed in some way by medical errors.

The statistics indicate as many as 9 million patients nationwide and between 400,000 and 528,000 patients in Illinois are harmed each year.

Misdiagnosis, even if 'signs' are not picked up on and responded to, may result in any of many outcomes. Misdiagnosing death that results in being placed on the LCP may have only one outcome.

It is time, perhaps, to come full circle and return to the petition raised by Dr Natalie Silvey and distributed on Twitter.
A signatory of that prestigious collection of names includes a Dr. H Shipman.

1197DrSarah-Jayne HerringtonN/GN/GUKN/GNov 04, 2012
1196DrSarah CookN/GN/GN/GN/GNov 04, 2012
1195DrH ShipmanN/GN/GUKViewNov 04, 2012

What follows is pertinent to the current issues discussed here.

What follows was published in these pages in November last year.


Treating someone as a category instead of as a person.

Classifying someone as a candidate for the LCP places them in a particular category. Once they have been boarded on the bus, it blinkers the conductor’s vision to any other eventuality - that, perhaps, they may have been given the wrong ticket. The Pathway has a predetermined destination which finality cannot be emphasised enough. Fact: Death really is the final finality in life.

There are stories and reports of the LCP being a ‘Lazarus Care Pathway’ but these are cases where the patient recovers despite the treatment recommendations of LCP; what proportion of patients do not recover becauseof the treatment recommendations of LCP?

These recommendations do not pay attention to the symptoms as they present but actually advise to ‘Avoid Delay & Crisis’ by prescribing, even in the absence of the symptom(s), to pre-empt the predicted appearance of the symptom(s)!*

*(End of Life Care - Symptom Control documents from NHS Milton Keynes)

Intrusions and interventions are also discontinued under these treatment recommendations.

“It is one thing to discontinue an intravenous infusion when the end is imminent; quite another to restrict fluids based on a prediction of how much longer a patient has to live.”

The correlation to draw from this statement is that it is unsafe to withdraw an intervention solely on the basis of a prognostic forecast. Prediction is always a hit and miss affair, as any astrologer will tell you!

Then, how unsafe must it be to proceed with an intervention on the same basis? What are the real statistics? Can we know when outcomes are predetermined by therapy and the ‘therapy’ is to place the person on a Pathway to a predetermined destination which really is a final destination?

This is Mail Online:

My husband had beaten cancer, then doctors WRONGLY told him it had returned and sent him to a hospice who let him die

A grandfather who beat cancer was wrongly told the disease had returned and left to die at a hospice which pioneered a controversial 'death pathway'.

Doctors said there was nothing more they could do for 76-year- old Jack Jones, and his family claim he was denied food, water and medication except painkillers.

He died within two weeks. But tests after his death found that his cancer had not come back and he was in fact suffering from pneumonia brought on by a chest infection.

To his family's horror, they were told he could have recovered if he'd been given the correct treatment.

Pat Jones and her late husband Jack
Death pathway: Jack and Pat Jones pictured about ten years ago. Jack was left to die after
doctors decided his 'cancer' was terminal and stopped feeding him

Yesterday, after being given an £18,000 pay-out over her ordeal, his widow Pat branded his treatment 'barbaric' and accused the doctors of manslaughter.

Mr Jones was being cared for at a hospice which was central to the contentious Liverpool Care Pathway under which dying patients have their life support taken away, although the hospice claims it wasn't officially applied in his case.

The scheme is used by hundreds of hospitals and care homes, and is followed in as many as 20,000 deaths a year.

Supporters say it brings dignity to a patient's final hours, but critics fear that some are placed into it incorrectly.

Mr Jones, a retired bricklayer with two daughters, was diagnosed with stomach cancer in May 2005. After undergoing chemotherapy, he had his stomach removed by surgeons at Royal Liverpool Hospital that September.

He was told he was in remission from cancer, but the grandfather of two continued to suffer pain following the operation as well as difficulties in eating, and on January 3, 2006, he went to the city's Marie Curie hospice for respite care.

While there, however, his family were told the cancer had returned by Dr Alison Coackley, a palliative medicine consultant who played a key role in drawing up the Liverpool Care Pathway.

Despite the fact that no tests were carried out to confirm the diagnosis, his family say doctors instructed nurses to stop giving him food and fluids.

Misdiagnosed: Jack's widow Pat has been paid an £18,000 settlement
although health bosses refused to admit liability

The only medication he was permitted were painkillers, and he slipped into semi- consciousness without the chest infection being diagnosed and died on January 14.

But a post-mortem examination found he was free of cancer and had in fact died of pneumonia.

Reports commissioned by Mrs Jones's solicitor concluded that with antibiotics and a rehydrating drip he could have made a full recovery and survived for at least another two years.

The hospice and the doctors who treated Mr Jones continue to deny liability, but his widow has now accepted an £18,000 out-of-court settlement after being told she would otherwise lose her legal aid.

Yesterday she said: 'If they'd only treated his chest infection, my husband could well still be alive today.

'We fought in the hospice to get Jack the right treatment and they blocked us, making us feel we were a nuisance.

'I was worried it was pneumonia, I wanted them to check his chest, but they wouldn't.'

Mrs Jones and the family want to know whether her husband was treated under the Liverpool Care Pathway.

She added: 'Jack was the life and soul of the party. He was a true gentleman. As far as I'm concerned, his death was manslaughter. It's barbaric and I don't want any other family to go through what we've had to.'

The 75-year-old, of Childwall, Liverpool, plans to report Dr Coackley and another doctor to the General Medical Council. Dr Coackley, 45, worked with Professor John Ellershaw at the hospice in Liverpool at a time when he was heading the writing of the LCP policy.

One article they published together last year said: 'Futile treatments should . . . be discontinued at this time and consideration should be given to the discontinuation of antibiotics and blood tests.'

Mrs Jones's solicitor, Michael Danby, said: 'This is a particularly sad case as it was entirely preventable. If they had examinedhis chest, they would have diagnosed the infection, and he could have been treated.'

The hospice's lawyer, Dorothy Flower, said it had settled the case to enable Mrs Jones to grieve for her husband, but did not accept liability. 'Some things are done for economic reasons, and a case like this costs a huge amount of money, which would do nobody any good,' she said.

Marie Curie cancer Care said it could not comment on Mr Jones's case due to patient confidentiality. However, it insists that the Liverpool Care Pathway requires doctors to monitor patients regularly.

Will Dr. Christian refer to this tragic story as just another "Daily Failure"?

Would he dare to sport such flippant comments? Could he be so dismissive of the suffering that has been and is being caused?

Then, to paraphrase the Bard:

     "Our names they are nothin'
     Our hurt it means less
     For we are but victims
     Of the NHS"

"With God On Our Side" - Bob Dylan

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