Liverpool Care Pathway – Those Who Count For Less

This from The Telegraph & Argus -

7:00am Saturday 3rd November 2012 in News

Bradford health chiefs defend end of life care method

Health chiefs in the Bradford district have defended the use of a controversial end-of-life care pathway for terminally ill patients in the face of negative press nationally.

Eighty-five per cent of trusts nationally, including Bradford Teaching Hospitals NHS Foundation Trust, Airedale NHS Foundation Trust and Bradford District Care Trust, have adopted the Liverpool Care Pathway (LCP) which can involve withholding food, drink and treatment from terminally-ill patients

Almost two-thirds of trusts that have used the LCP have received financial incentives totalling millions of pounds, according to figures obtained by a national newspaper, including Bradford Teaching Hospitals NHS Foundation Trust which qualified for £490,000 over two years after doubling the number dying on the pathway to 51 per cent.

The care pathway is supported by leading clinicians and charities such as Marie Curie. It is also endorsed by NICE and the Department of Health as a way to help meet the needs of those who are nearing the end of their life.

However, it has come under scrutiny recently, with reports suggesting hospitals may be employing the method to cut costs and save on bed spaces. Earlier this week, Tory peer Baroness Knight called for an independent inquiry into the pathway.

Health minister Norman Lamb has called a meeting of doctors and patients’ groups to discuss mounting concerns.

One national paper reported how an 82-year-old woman in Blackpool was given two days to live and had feeding tubes removed, but made a remarkable recovery after her family defied doctors’ orders and gave her water through a straw.

Payments are made to hospital trusts under a system called Commissioning for Quality and Innovation (CQUIN), where the NHS commissioners “reward excellence” by paying trusts to meet care targets.

A spokesman for NHS Airedale, Bradford and Leeds said: “In Bradford and Airedale, appropriate CQUIN payments were made to local NHS trusts to promote good, holistic care for patients at the end of their life.

“This included ensuring more patients died in the place of their choice, promoting staff education around care for the dying and increasing the number of dying patients cared for in line with the Liverpool Care Pathway.

“Ensuring people receive high-quality end of life care services is a priority for us and we have strong local clinical support for implementing the Liverpool Care Pathway as part of this. We support the appropriate use of the Liverpool Care Pathway as a guide to caring for a person with dignity at the end of their life.”

A spokesman for Bradford Teaching Hospitals NHS Foundation Trust said: “The LCP is the gold standard of treatment and care for those patients nearing the end of life. It ensures that these most vulnerable of patients are treated with dignity and respect in their last days and hours. The LCP enables us, as health professionals, to follow a carefully and well-thought out set of guidelines which provides expert guidance so that we know we are carrying out our jobs to the best of our ability and in the best interests of those patients nearing the end of their lives.

“All decisions and medical treatments are made on an individual patient basis and this must be discussed with the patients (where feasible) and their next-of-kin. Patients’ care is reviewed regularly and adjusted accordingly. It is important to stress that being put on the LCP is not a one-way process. If the patient’s condition improves, care is reviewed and the pathway stopped.”

Andrew Catto, medical director at Airedale NHS Foundation Trust said: “Airedale supports the appropriate use of the Liverpool Care Pathway and we would like to reassure our patients and their families and carers that it is not in any way about ending life, but rather about supporting the delivery of excellent end of life care.”

Nicola Lees, deputy chief executive and director of nursing at Bradford District Care Trust said: “We support the appropriate use of the Liverpool Care Pathway as a guide to caring for a person with dignity in the last hours and days of life.”

This is important. This concerns Bradford Teaching Hospitals NHS Foundation Trust. This is taken from the report above -

"A spokesman for Bradford Teaching Hospitals NHS Foundation Trust said: “The LCP is the gold standard of treatment and care for those patients nearing the end of life. It ensures that these most vulnerable of patients are treated with dignity and respect in their last days and hours. The LCP enables us, as health professionals, to follow a carefully and well-thought out set of guidelines which provides expert guidance so that we know we are carrying out our jobs to the best of our ability and in the best interests of those patients nearing the end of their lives.

“All decisions and medical treatments are made on an individual patient basis and this must be discussed with the patients (where feasible) and their next-of-kin. Patients’ care is reviewed regularly and adjusted accordingly. It is important to stress that being put on the LCP is not a one-way process. If the patient’s condition improves, care is reviewed and the pathway stopped.”

This is important. This concerns Bradford Teaching Hospitals NHS Foundation Trust. This is taken from the report below -

"An independent expert said if observations had been carried out regularly and diligently by staff at Bradford Royal Infirmary, Laura's tragically young life could have been saved.

"He told the hearing the problem with observations exemplified a widespread failure in the NHS.

"Nurses are pre-occupied with "box ticking" and taking temperature and pulse have become 'Cinderella tasks', the inquest heard."

Nurses pre-occupied with "box ticking" are not going to readily recognise the subtle signs that might indicate improvement when the “LCP-ed” patient is "reviewed". A patient swept along on the Pathway, already diagnosed as “dying”, is not readily going to be brought back and taken off it.

The problem with observations exemplifies a "widespread failure" in the NHS. If a young girl with her whole life ahead of her counts for nothing, then someone diagnosed as being at the very end of their life is going to count for significantly less.

This is The Telegraph report quoted above (Hospital tick-box culture contributed to death of girl, 18) -

Hospital tick-box culture contributed to death of girl, 18

The life of a teenage hairdresser could have been saved if a blundering hospital had observed her properly, a coroner has ruled.

Laura Garner died in September 2009 at Bradford Royal Infirmary
following a kidney infection Photo: Ross Parry

By Telegraph reporters 10.15AM BST 06 Jul 2012

Normally healthy Laura Garner, 18, died just over 24 hours after being admitted to hospital on September 22, 2009, suffering from a fever and an abnormally fast heart rate.

A post-mortem revealed she died as a result of septicaemia and acute pyelonephritis - a serious bacterial infection of the kidney - but a three-day inquest into her death revealed missed chances to diagnose her.

An independent expert said if observations had been carried out regularly and diligently by staff at Bradford Royal Infirmary, Laura's tragically young life could have been saved.

He told the hearing the problem with observations exemplified a widespread failure in the NHS.

Nurses are pre-occupied with "box ticking" and taking temperature and pulse have become 'cinderella tasks', the inquest heard.

Coroner Prof Paul Marks, recording a narrative verdict at Bradford Coroner's Court yesterday, said that despite Laura, of Baildon, West Yorks., undergoing a serious procedure to determine whether or not she was suffering from appendicitis, regular observations were not carried out, with one gap between obs being around 11 hours.

Prof Marks said: "There were no basic observations carried out on her until 9.30pm on September 23 at which point her blood pressure was unrecordable.

"Such observations, if made, are likely to have shown evidence of deterioration and if acted upon may have permitted therapeutic intervention which evidence shows could have saved her life."

Speaking after the inquest, Laura's mother Anne Garner, who indicated the family would be pursuing a civil claim against the Trust, said: "Hearing the expert evidence that said my daughter would still be with us today if they had done their job and checked her was the hardest part.

"I do not want anybody else to go through what we have gone through. That's why we wanted this inquest, to make sure no other family has to go through this."

The inquest heard Laura died just after midnight on September 24 after suffering a cardiac arrest. Her mother had sent Laura a text at 11.45pm to say she loved her, but did not get a reply. A phone call from the hospital came shortly after 1am to say Laura had died.

The coroner heard evidence from Professor Michael McMahon, a consultant surgeon with 30 years' experience. He told the hearing that there had been a "systems" failure in Laura's case and said the incident exemplified a failure in the NHS as a whole.

He told the court: "On the balance of probability, had her observations been carried out regularly and diligently then her impending problem would have been recognised earlier.

"If the diagnosis had been made before the collapse then a combination of antibiotic therapy and, in the first instance, physiological support given, she should have achieved survival.

"There was a low chance of mortality on the basis of the fact she was a young woman and otherwise fit. The likelihood of survival was more than 51 per cent.

"I would have to say on the balance of probability there was a missed opportunity."

Prof McMahon told the inquest that Laura's was an especially ferocious case of pyelonephritis, especially in an otherwise well young girl, and in this case the septicaemia had overwhelmed her.

He said: "This was not only a tragic case but an unusual case and most of the staff who saw her would not have seen such a severe attack of acute pyelonephritis as that suffered by Laura. It is not a diagnosis that immediately comes to mind."

But he added that the case "classically exemplified" a failure in the NHS where taking the pulse and temperature of a patient had become a "Cinderella task".

"A very similar picture frequently emerges of observations that are not done or their importance goes unrecognised," he said.

"Nurses have to tick boxes on a whole host of things and the priority given to observations has fallen by the wayside and are carried out by care assistants and auxiliaries and not registered nurses."

The coroner used his powers under rule 43 to recommend that policies around observations at the hospital are improved and also that the Trust implement a better system of monitoring the crash trolley.

The trolley used during Laura's resuscitation was found to be missing defibrillation pads and, despite the fact that they would not have saved her life, the coroner directed the hospital to implement a better system of checks.

The inquest also heard that an on-duty doctor had recommended twice that Laura be given antibiotics - but these were never prescribed to the stricken trainee beautician. However, it was decided that these antibiotics would not have saved her life.

Mrs Garner also gave evidence to the hearing, saying she had repeatedly asked hospital staff to be allowed to stay with her distressed daughter, but this was refused as Laura was classed as an adult.

Speaking after the case, she said: "She was just a bairn - only just 18. I had to battle with them constantly to let me stay with her.

"She was a wonderful young girl, a typical 18-year-old who lived every minute of her life and didn't miss a minute of it. It doesn't get any easier - I was hoping the inquest would help even a little bit but I don't think anything will."

Laura's father Steve added: "I still visit her everyday and will continue to. She was such a popular girl, there were over 300 friends at her funeral and they still all go along to visit her."

Bradford Teaching Hospitals NHS Foundation Trust prepared a serious incident report following Laura's death which concluded that there were "deficiencies in the basic medical processes of differential diagnosis, investigation and treatment".

Mrs Garner added: "They have been very frank and open with us from the start but these rule 43 directions mean they have to do what is being asked of them.

"I just hope that prevents any family going through what we have been through. I can't believe the way she has been treated."