Monday, 26 November 2012

Liverpool Care Pathway – Making Amends

Massimo Costantini, I've been reading that name all over the place...Why do so many of these, by now, familiar, names of palliative care researchers crop up together time and again, Eldoel? And so often in the same context?
Thankyou for that, Harlow Blogger. I do apologise for not responding to comments on this blog. I make no excuses, although there are many, for it is inexcusable. I will make amends.

Yes, Massimo Costantini...

A study, started in Italy, is mentioned by Dr. D'Costa in this post:

The majority of doctors may not be aware that , regrettably the lcp is not backed by the gold standard of evidence of an rct. Perhaps the climate is right for an rct of the lcp vs usual care. A similar study has been started in Italy (4). 
4)Costantini et al; The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial.BMC Health Services Research 2011, 11:13 doi:10.1186/1472-6963-11-13 
Domnik Felix D'Costa, consultant physician 
royal wolverhampton hospitals, wv10 0qp 

This appears to refer to this study -
A service of the U.S. National Institutes of Health

The Effectiveness of the LCP in Improving End of Life Care for Dying Cancer Patients in Hospital.

This study is ongoing, but not recruiting participants.
Information provided by (Responsible Party):
Regional Palliative Care Network

The purpose of this study is to evaluate the effectiveness of the LCP-I Program in improving the quality of end-of-life care provided to cancer patients who die on hospital medical wards as compared to standard healthcare practices.
Contacts and Locations
Please refer to this study by its identifier: NCT01081899

National Cancer Research Institute
Genoa, Italy, 16132
Sponsors and Collaborators
Regional Palliative Care Network

Principal Investigator:Massimo Costantini, MD
National Cancer Research Institute  - Genoa (Italy)

 More Information

No publications provided by Regional Palliative Care Network

Additional publications automatically indexed to this study by Identifier (NCT Number):

Responsible Party:Regional Palliative Care Network Identifier:NCT01081899     History of Changes
Other Study ID Numbers:RFPS-2006-6-341619
Study First Received:March 4, 2010
Last Updated:November 11, 2011
Health Authority:Italy: Ministry of Health processed this record on November 25, 2012

Under More Information, it is stated, "No publications provided by Regional Palliative Care Network".

Your post, here, is relevant, Harlow Blogger -

Liverpool Care Pathway – Anonymous Voices And The Silence Of The Lambs

  1. “Since the 1990s, the LCP has been....supported by evidence and research of the highest quality...”

    However, I am concerned about whether there might be considered to be conflicts of interest in respect of some of this research. This is what I was refering to in my message yesterday.

    A further, related, concern is the corporate nature of at least some of the charitable organisations carrying out and, or, funding the research into end of life care and the LCP and influencing government policy in this area. Once again, I am concerned about whether this might be considered to represent a conflict of interest. One of these organisations is a multi-million pound concern.

The 'Additional publication' mentioned above is here -


The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial

Massimo Costantini,corresponding author1 Simona Ottonelli,1 Laura Canavacci,2 Fabio Pellegrini,3,4 and Monica Beccaro1the LCP Randomised Italian Cluster Trial Study Group


  • EAPC. Atlas of Palliative Care in Europe. European Association for Palliative Care: IAHPC Press; Milano; 2007.
  • Higginson IJ, Sen-Gupta GJA. Place of care in advanced cancer: a qualitative systematic literature review of patients preferences. J Palliat Med. 2000;3:287–300. doi: 10.1089/jpm.2000.3.287. [PubMed] [Cross Ref]
  • Beccaro M, Costantini M, Giorgi Rossi P, Miccinesi G, Grimaldi M, Bruzzi P. ISDOC Study Group. Actual and preferred place of death of cancer patients. Results from the Italian Survey of the Dying of Cancer. J Epidemiol Comm Health. 2006;60:412–416. doi: 10.1136/jech.2005.043646. [Cross Ref]
  • Davies E, Higginson IJ. Palliative care: the Solid Facts. WHO Regional Office for Europe, Copenhagen; 2004.
 I have reproduced part of the References sections because it is here that conflicts of interest can arise. Acknowledgements and References are cited in research papers - as I understand it - as independent sources of authority to confirm points of validity in the research being undertaken.

Professor Massimo Costantini is involved in advisory and collaborative capacities in palliative care in a number of bodies and that may be why  these, by now, familiar, names of palliative care researchers crop up together time and again.

In their role in advising and collaborating, I would imagine they may participate in numerous different studies in their field. If these studies are then cited as a point of reference in other studies in which they have been involved, then they are, effectively, citing themselves to provide authority to their own study. That is corrupt and nullifies the work.

It may not be obvious that this is the case. It may be that the work or opinion of another body is cited. If, however, members of the particular research team are members of this cited body, again, they are, effectively, citing themselves to provide authority to their own study. That is corrupt and nullifies the work.(NICE, DOH, Marie Curie, all cite each other and others in like manner).

This is, regrettably  not an uncommon practice. The well-documented medical controversy between ILADS and the corrupt practices of IDSA are well documented on the net. (See - Dr. Jemsek's license suspended because he adhered to the ILADS guidelines and the antitrust  investigation by the Connecticut Attorney General).

Various organisations are cited to substantiate the IDSA guidelines, namely the CDC, ALDF and EUCALB - when those very organisations actually hold no independent viewpoint at all but merely voice and duplicate that of the IDSA Lyme disease panel. Different organisations are cited to give the appearance of wider and more authoritative backing from different, independent sources when the membership of these organisations actually contains the very same people amongst their number and, therefore, disqualifies them as an independent source.

There is no corroborating evidence from varying authoritative points of reference, therefore, to support the view promulgated by IDSA; there is, in fact, only one point of reference – the guidelines as set out by the IDSA Lyme disease panel, which is currently under investigation for GROSS conflicts of interest!

Mark Klempner, an IDSA Lyme disease Practice Guideline author, is also an associate editor for the New England Journal of Medicine. The New England Medical Journal plum-picked those articles which supported his viewpoints and excluded from publication those that did not. (Curiously, the Advancing Quality Alliance (AQuA) page (mentioned on this Blog) actually sports a link to the New England Journal of Medicine – No connection, of course; mentioned just in passing).

Returning to Professor Massimo Costantini -

He is involved in advisory and collaborative capacities in palliative care.

He has had work published in Journal of Pain and Symptom Management (here) and on behalf of the Ligurian Research Group (here)

He is Consultant In Clinical Epidemiology and Director of the Regional Palliative Care Network, National Cancer Research Institute of Genoa

He is a Member of the Techno-Scientific Committee at The Maruzza Foundation. This seeks to promote palliative care programs and disseminate the culture of palliative care by organizing round-tables, workshops, conventions and training opportunities, through book publication and awareness campaigns. The Foundation provides care and support for patients with incurable illness through conventions stipulated with numerous associations and public hospitals. The Maruzza Foundation is striving at a national and international level to bring about important institutional changes, working directly with palliative care experts and policy makers to develop recommendations for the implementation of innovative health care policies through advocacy for pilot projects and research programs.

"We want to establish the right to access care even if recovery is not possible"

(Oh, to go back to the days when the goodies wore the white hats and the baddies wore the black hats...)

He has collaborated with the Cicely Saunders Institute at Kings college, London.

He sits on the editorial board of Health and Quality of Life Outcomes.

White hat or black hat? Sinister, or all just 'synastry'? Either way, he is well-placed to position himself for self-citation.

Harlow Blogger posted to the same Blog -

Liverpool Care Pathway – Anonymous Voices And The Silence Of The Lambs
  1. In my opinion, all deaths on the Liverpool pathway are equivocal deaths, because the true cause of death - whether underlying illness, treatments given or withdrawn under the LCP (drugs administered or withdrawn, deliberate dehydration, withdrawal of nutrition) or some combination of these factors, or even complications arising from them - cannot be known.

    As I understand it, English law requires a post mortem to be held in the case of all equivocal deaths and requires Inquests to be held in the case of suspicious deaths.

    I've read that few post mortems are conducted in the case of those who die on the LCP - yet these must include many equivocal deaths. Is the legal requirement for post mortem being evaded in the case of those who die on the LCP? If so, why?

    Also, does the law not require the true cause of death to be recorded on the death certificate? Yet how can the true cause of death be recorded for those who died on the LCP and without post mortems being carried out?

Harlow Blogger's sentiments have been voiced in these pages. What does go on the death certificate? Well, it's not 'LCP-ed'!

In the case of 'suspicious deaths', the police attend, but this does not assume a post mortem will be called.

In the case of my mother's death, I said to the officer whose face appeared through the curtains around the bed in A & E, that they'd dosed her with morphine. His response was that this would be a police matter if that was the case. I was still full of disbelief, unaware they had withdrawn all medication, that such a thing as The Pathway even existed! I retracted. It could not be, it just could not be!

We insisted on a post mortem.This took place - on the other side of the county, for whatever reason. They refused to test for morphine levels.

In this respect, thankyou for this -

  1. they do appear to put the midazolam in first, to ensure the patient is unconcious. This allows them to do whatever they want in the patient's 'best interests'..ho ho. You should try to find out how much of these drugs they administered by finding out who your local police 'controlled drug liaison officer' is (every police force is supposed to have one now)...they can go and inspect the controlled drugs registers . The actual amount put on the ward for your mother should have been put in a locked cupboard and signed for...the amounts given to your mum should have been recorded on her records..any left over is supposed to either be witnessed being destroyed by two nurses OR returned to the pharmacy. Either way, there is supposed to be an 'audit trail' of ALL controlled drugs, to stop nurses 'misappropriating ' any for their own use AND to stop deliberate overdoses. My hospital had an audit 4 months before my father died , and no less than 60% of the CD registers were not up to standard!!! They dont bother with audits in pallio units, as they just accept large doses are used, and dont give a damn. Try the police ...they're useless, but if youre going to this meeting, you should tape the police show that none of the safeguards put in post shipman are working, and that vast amounts of trust are placed on the word of 'caring' nurses in such units ....

  2. I must add that rendering someone unconscious with midazolam is NOT the same as someone becoming unconcious because of a natural is an assault. This is a very important is a ruse they use to facilitate giving a patient they are bored with treating any tablets at any dose they choose....the thing about midazolam is that it is eliminated in the urine very quickly, so even a post mortem blood sample wont show it...
    If I sedate someone before I murder them, I dont actually expect a judge to take time off the sentence because they were unconcious when I suffocated them, do I?

By the time all this comes out a lot more will come out if we can't squeeze it out first. But justice will prevail, however long it takes.

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