Tuesday, 8 January 2013

Liverpool Care Pathway - The Nail In The Coffin

"I'd rather be a hammer than a nail..."

They are dying to implement this Pathway. They are not going to roll it back; it is too well advanced in every nook and cranny of every social setting.

A hammer can be used to knock in a nail or knock someone over the head. They are not going to blame the tool; they are going to blame the wielder of the tool.
"Placing a patient on the Pathway "is a decision with an end in view. The patient is dying. Why? Because we say they are dying. Why? Because we have decided.” ((Dr Philip Howard)
"The report highlights a myriad of challenges of mainstreaming palliative care: the fact that most common chronic diseases (unlike cancer) have uncertain prognoses, which makes assessment of the need for palliative care difficult... "("The Solid Facts: Palliative Care" edited by Elizabeth Davies and Irene J. Higginson - Ethos Perspectives) — May 2007 Soh Tze Min and Sheila Ng
"Without a doubt, end-of-life care is fraught with complexity and controversy. For example, there is continuing debate whether it devalues life by abandoning curative efforts too early, or is more respectful of life as it seeks to give the dying greater dignity and quality of life. While most respect individual choice and one's right to die with dignity, interpretations—whether individual, societal, cultural, religious or clinical—of what constitutes "quality of life" in one's dying years vary greatly. There is also a lingering perception that palliative care can result in substandard medical treatment, or is a way to end the burden of caregivers."Ethos Perspectives — May 2007 Soh Tze Min and Sheila Ng Social Policy)

The Government intends to put the NHS on a sound financial footing to secure its future. This is how they intend to do this: 

In your elder years, if you show signs of illness, weakness or frailty, certainly disability or dementia - and strokes (click here) are included in this classification - you will be pigeon-holed and you will be marked down for the GP 1% campaign. The GPs sift through their patient allocation death list and categorise you for palliative rather than curative care.

This is what they are calling their six steps to success in their selection and culling program.

You don't even have to read between the lines to get the drift of their intentions.

If you want help to live and not to die, beware that visit to the surgery. The 'family doctor' is not just 'sizing you up' but 'measuring you up'.

The 'family doctor' has undertaken an entirely new role!

Doctors have donned their Sunday-best undertaker's suit.

"Outcome measures are widely used in health research to describe patient populations or to assess the effectiveness of interventions, but they are not, as yet, always incorporated into routine clinical practice. However, with the increasing focus on patient autonomy, equitable service delivery and transparent information compelling service providers, healthcare commissioners and funders to demonstrate effectiveness and value for money, outcome measurement is becoming a more important procedure to consider. In addition, funding from governments or commissioners is becoming more often a condition for ongoing provision of outcomes data. The use of outcome measurement is therefore becoming increasingly important in healthcare, both in general and in palliative care in particular."

Income funding provision is dependant upon provision of outcomes data. Interventions (curative options) will be measured against potential effectiveness and value for money...

Chronic does not mean 'at death's door'...

There are major changes to commissioning within the health system in England which are due to come into effect in April of this year. The Clinical Commissioning Groups (CCGs) have identified the economic benefits of eliminating emergency admissions in the 'final years' of life. Chronic does not mean 'at death's door', but 'Chronic' has thus been identified. 

The NHS Commissioning Board (NHS CB), plays a key role in the Government’s vision to modernise the health service with the key aim of "securing the best possible health outcomes for patients".

That is not the best, but the best possible.

"Reducing demand and redesigning care pathways to treat patients in the most appropriate setting are key ways of generating savings." 

The Communitarian statistics stand out –

The implications are clear: a recent study showed that if past trends in terms of reductions in home deaths continue, in order to meet the projected increase in the numbers of annual deaths (585,000 in 2030) there would be a need to expand inpatient facilities by over 20%.

In the United States it is estimated that 20%
of healthcare expenditure is related to end of life patients. Patients in their last year of life account for 80% of the Federal Medicare Programme expenditures, half of it by those in their last two months of their life. Similarly, in the United Kingdom about 20% of hospital bed days are covered by end of life care.
The review of the literature revealed that there is consistent and robust evidence that palliative care services reduce the symptom burden and improves satisfaction and quality of life of patients and caregivers. Almost all studies that look at costs find economic benefits for palliative care; the evidence is clearer for cancer patients and predominantly from the United States. Any savings result from fewer hospitalisations and reduced use of intensive acute care resources.

The implicit assumption is that the time patients spend in hospitals could be reduced by transferring them to their preferred care setting at the end of their life. By providing end of life care in the community both the number of unplanned emergency admissions and the days spent in hospital could be decreased. With the use of the economic model we estimate the days of acute care which could be potentially avoided as well as the associated amount of resources which could be made available for redeployment.

Overall, the study results consistently point in the same direction as the literature: there is real potential for palliative care services to reduce expenditures associated with hospitalisation while at the same time accommodating the expressed preferences of patients.

(The potential cost savings of greater use of home and hospice-based end of life care in England Evi Hatziandreu, Fragiskos Archontakis, Andrew Daly in conjunction with the National Audit Office)

Some key findings

As expected, most people dying were over 65

Using Gold Standard Framework categories, frailty (42%) was more common as the
underlying reason for dying than cancer (30%) or chronic disease (20%). 8% were
assessed as dying ‘unexpectedly’.

Up to 25% of those dying may have had dementia.

Clinical decisions about death are often made at a late stage so that there is not enough time to consider alternatives.

The aim of the project in Sheffield has been to explore the potential for change in care pathways for people at the end of life, and in particular to consider alternatives to patients dying in hospital.

Earlier clinical decisions that the patient is nearing the end of life

(Identifying Alternatives to Hospital for People 
at the End of Life 
The Balance of Care Group in association with the National Audit Office 5 September 2008)

This document is a guide to support practices implementing a pathway change for GP Palliative Care Registers.

End of Life is a priority for the CCG and poor co-ordination of care is a cause of emergency admissions. Carers frequently tell us about poor coordination of care for people at the end of their life and within the new NHS outcomes framework one of the outcomes to be measured is carers satisfaction with their loved ones end of life care. It is also referenced in the Clear & Credible plan and Joint Strategic Needs Assessment.

The palliative care registers were introduced as a quality and outcome framework (QOF) measure to try to improve the care of people at the end of their life. General practices should have a register of all patients with supportive or palliative care needs. This identifies both cancer and non-cancer patients who may be in their last year of life.

Research and local experience tells us that the registers are used in very different ways within and between general practices. See information below.

The North East Strategic Health Authority (SHA) end of life clinical innovation team (CIT) has been working with a number of dedicated clinicians and IT experts to develop this ‘How to guide to try and make it easier for you to manage your register effectively.

This pathway change aims to go beyond standard QOF indicators to improve and standardise End of Life Care.

The  next few sections lay out steps from the‘How to guide’.

Step 1  managing your palliative care register effectively

To ensure more chronic diseases are included on the register you may like to think about using the “Would you be surprised if this patient died in the next 6 -12 months?” question. Please refer to the 
surprise question briefing paper in section 6 of the ‘How to’ for more information.

One per cent of the English population dies each year, only 25 per cent die from cancer.  Do you know who is most likely to die from your list in the next 12%months? It will be about one per cent of your patients; most of them will be elderly. Are they on your register? Have you created the opportunity to discuss their wishes with them? It will be a small investment of time now which could save you many frustrating conversations later this year as their unplanned admissions, falls and
infections mount(Dying Matters Coalition).

The average life expectancy for people in a nursing home bed is less than a year so you might like to think  about having a register that includes them. Many will already have had some kind of care planning done within their care home.

The gold standards framework (GSF) prognostic tool containing data about predicting mortality is given in Section 10 of the ‘How to’ guide.

The following table indicates the cause of death by percentage for some major diseases in the north east. To ensure fair access to palliative care services we suggest that you should be aiming for as close  to these percentages as possible on your end of life register. This may require a stepwise approach as most registers are currently dominated by cancer patients.

Step 2  Meetings

Monthly meetings are essential to discuss the palliative care needs of patients whose condition may deteriorate rapidly  with a corresponding impact on timely care  planning. Suggested standard operating procedures for Meetings are in the ‘How to’guide’.

Obviously, adding those people with chronic diseases to the register will make the register larger so you may like to think about a system to prevent your register becoming unmanageable.

You may like to introduce a traffic light system:

Red patients in the last few days of life
Amber patients in the last few weeks of life or who are deteriorating rapidly or very 
complex,should be discussed at monthly meetings
Green patients in the last year of life who are on the register and flagged in the notes.

QP Suggested Evidence

Your practice may already have a template which you use for your Palliative care register and there are examples available in the full ‘how to' guide, but implementation is not part of this scheme.

Use of medicines in care homes and end of life care

The objective of this study is to explore and provide estimates of the financial
consequences of decreasing reliance on acute care during the last year of life.

The annual number of deaths is expected to rise by 17% from 2012 to 2030. By that year 585.000 deaths are forecasted. People will be dying increasingly at older ages. Indeed, deaths among the very elderly, those aged 85+, will account for almost 45% of the deaths in 2030. The shift in degenerative conditions is accompanied by changes in the patterns of death to a more gradual deterioration as the boundaries between being ill and dying have been obscured and prolonged.10 Thus, end of life is not a related to a brief illness but to a more prolonged period.

These trends have also resource implications. In the United States it is estimated that 20% of healthcare expenditure is related to end of life patients. Patients in their last year of life account for 80% of the Federal Medicare Programme expenditures, half of it by those in their last two months of their life. Similarly, in the United Kingdom about 20% of hospital bed days are covered by end of life care.11 The pattern is expected to be similar in other western European countries. Since medical care provided in hospital consumes more resources and is relatively expensive, reducing undesirable hospital admissions and the intensity of services provided (intensive care unit (ICU), ancillary services, pharmacy, etc.), could reduce the overall financial burden of end of life care.

"In expanding palliative care, one must, however, be mindful of vulnerable groups, such as the minorities or the disabled, and ensure that they have access to palliative treatment, without compromising their curative options." (Civil Service College)
In expanding palliative care, it is acknowledged that this is precisely what they are doing and that this is Government Policy: The curative options are being sacrificed.

This is back-door euthanasia!


Vulnerable groups are already targeted for palliative rather than curative care -

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.
There are more bed-blockers to shift. And where will this lead...?

Where it has already led.

There is an increasing distinction between end of life care and palliative care. The latter is being accepted to cover patients of any age of advanced and life-threatening illness who may still be receiving curative care and are not considered to be in their last 6–12 months of their life.(End of life care as defined by the National Council for Palliative Care)

This is BBC News -
Learning disabled care is 'worse'

By Geoff Adams-Spink 
Age & disability correspondent, BBC News website

Page last updated at 23:07 GMT, Sunday, 20 June 2010 00:07 UK

People with learning disabilities receive worse healthcare than the rest of the population some doctors and nurses believe, according to a charity.
Mencap has found almost half of doctors and a third of nurses from a poll of poll of 1,084 think this is the case.
It is urging health trusts to sign a charter which sets out the rights of people with learning disabilities and the responsibilities of hospitals.
The government says that removing inequalities is a priority.
Mencap's research - conducted by ICM among more than 1,000 doctors and nurses within the past month - also revealed 45% of doctors and a third of nurses had witnessed a patient with a learning disability being neglected or being denied their dignity.
Four out of 10 doctors and a third of nurses surveyed thought that people with learning disabilities were discriminated against in the NHS.
Despite enjoying legal protection, the survey found learning disabled people were being failed because more than a third of health professionals had not had appropriate training.
Yet a majority of doctors and nurses admitted to needing specific guidance on how to meet the needs of learning disabled patients.
Health passport
Disability legislation requires health care providers to make "reasonable adjustments" to accommodate disabilities and long-term health conditions.
 She was denied her chance of life by doctors who discriminated against her 
Emma Kemp's mother, Jane
In the case of learning disabled people, a reasonable adjustment might include: allowing more time for consultations, using a patient's preferred method of communication and using their hospital passport.
A hospital or health passport is a document carried by a patient that includes key information about their condition, their likes and dislikes and things that they feel are important.
"Healthcare professionals have recognised they need more support to get it right when treating people with a learning disability," said Mencap Chief Executive, Mark Goldring.
He said that the charity's campaign called - Getting it Right - aims to ensure that ignorance need never be the cause of a learning disabled persoers."
n's death.
"Our charter sets out a standard of practice and will make health trusts accountable to people with a learning disability, their families and carTwenty-six year-old Emma Kemp had a 50% chance of surviving the cancer with which she was diagnosed, according to her mother, Jane.
But hospital staff were apparently worried that her learning disability would make her difficult to treat, so they decided not to treat her.
Eventually, Mrs Kemp agreed that her daughter should receive palliative care.
"She was denied her chance of life by doctors who discriminated against her," said Mrs Kemp.
Mrs Kemp asked one of her daughter's doctors what would happen if Emma hadn't had learning disabilities and she was told that treatment would begin immediately.
"When I agreed that Emma should only receive palliative care treatment, I did so because I was then told that Emma only had a 10% chance of survival and that it would be cruel to treat her," she said.
"I now know that this was not true; that I was misled into agreeing with the decision that cost my daughter her life."
The Getting it Right charter asks health professionals to:
• Ensure that "health passports" are available and used
  • Ensure that all staff understand the Mental Capacity Act
  • Appoint a learning disability liaison nurse in hospitals
  • Ensure that every person with a learning disability is able to have an annual health check
  • Ensure that all staff have learning disability awareness training
  • Ensure that patients' families and carers are listened to, respected and supported
  • Provide information in a format that is accessible to people with learning disabilities
  • Display the "Getting it Right" principles for all to see
The Department of Health says that, while improvements have been made, there is still "much to do".
"Health remains one of the three priorities for the government's learning disability strategy," a spokesperson said.

Department of Health spokespersons have said much...

You may find what follows abhorrent. Then again, you might not...

In the thirties, when euthanasia and doing the'kind' thing because it's for the best was popular in the States, in Nazi Germany, and elsewhere...

This poster was produced to show the economic benefits of it all. This same emphasis is made now and is what the Commissioners are underlining:

This is the poster the Nazis used to persuade the German Volk that they should support a similar 'mercy death' scheme in the 1930s...during the Depression....they felt by saying, 'This is how much it costs to feed this useless person' they'd win support...that is exactly how the NHS are persuading us to support the Liverpool Care Pathway...It reads:

 "60,000 Reichsmarks is what this person suffering from a hereditary defect costs the People's community during his lifetime. Fellow citizen, that is your money too. Read "[A] New People', the monthly magazine of the Bureau for Race Politics of the NSDAP."" 

The "People's community"...

The Government are now calling the National-socialist Health Service (NHS) "The People's NHS"...

GPs are drawing up their Death Lists.

At least the Nazi doctors were honest about what they were about - putting people down.

These 'liberal' ethicists are painting it over with Newspeak. They don't want to be tarred with the same brush; they're socialists, not national-socialists!

They want the old, the weak, the frail, to take on this responsibility for themselves - and acknowledge a duty to die, to go for the palliative rather than the curative option. What is the point of the futility of a few extra months, years of less than optimum life...?

The hammer has  hit home the final nail into the coffin.

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