Monday, 28 January 2013

Liverpool Care Pathway - The Sneak In The Waiting Room


Lunar New Year falls this year on February 10 which will inaugurate the Chinese year of the Snake.

2013 also inaugurates the CQUIN year of Dementia.

Healthcare professionals are being tasked to identify early signs of dementia. 

They have to be found so they can be helped... on their way.

Discussing the validity of hydration and nutrition, this is the British Medical Journal -

Dutch research reflects problems with the Liverpool care pathway


12 May 2008

With 30 years' experience as a geriatrician, I always found it difficult to predict death, which is what is being sought here, in order to implement the LCP appropriately. While the LPC offers useful guidelines on the management of end-of-life symptoms, it seems to be rushing in with sedation and opiates without considering whether hydration and nutrition are also still valid treatment.
Competing interests: None declared
Competing interests: None declared
Bruno Bubna-Kasteliz, Professional Adviser
Office of Health Ombudsman, Millbank, London W1P 4QP

Discussing the validity of hydration and nutrition, this is a comment left on these pages referencing a BMJ article -

  1. The following is from a study carried out in a nursing home in Holland for people with dementia:

    "Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study."

    BMJ 2002; 325 doi: (Published 7 December 2002)
    Cite this as: BMJ 2002;325:1326

    "The amazing recovery of Mrs R"

    "Mrs R, 81 years old, arrived at the nursing home in a bad state. After admission she deteriorated. She weighed less than 40 kg and was dehydrated. “In a dreadful state” was how the nursing staff described her. After discussing it with the family, doctor M decided to perform hypodermoclysis in both of Mrs R's legs.

    Doctor M: This caused tremendous opposition from the nursing staff. However could I think of artificially administrating fluids to a woman in that state? I really had to do my best to explain that I also have my medical responsibilities and had to try it. I must honestly admit that I, too, didn't have much hope. Well, that was three years ago, and if you see Mrs R now, would you ever imagine that she had been so far gone then? She's made a wonderful recovery. She walks around the ward all day long tidying up and really is the sunshine in house. I use the example of Mrs R whenever the nurses protest about hypodermoclysis."

    In the case of patients with dementia, hypodermoclysis is often done at night, while the patient sleeps, as this overcomes the problem of such patients pulling out the tubes used.

The June 2010 Macmillan End of Life Care Newsletter shares the National End of Life Care Programme logo and is published by NHS. This really is getting like a medical-palliative-pharmaceutical version of Ike's 'military-industrial complex'.

Mr. Lamb has said he is 'uncomfortable' with the word Pathway. The use of the word 'programme', however, is both worrying and problematical to anyone who has the slightest knowledge of the 1930s' end of life programmes and the horrific events which culminated in what became known as the Holocaust.
The Newsletter describes a new e-learning package for End of Life Care -

"Nearly all health and social care staff need training of some sort in end of life care. A new e-learning package aims to offer just that"

We are talking about someone dying.

In the context of End of Life training, it is inappropriate and, quite simply, offensive to describe the training offered as being "easy, fun and free". It is so described.

Dr. Bee Wee certainly seems to be 'having fun' in this photo-shoot picture from the Newsletter.

Were these 'fun' lessons devised by the same team that devised that infamous 'mission impossible' slide -

They have been discussing a document to put someone, a year hence, onto The Death Pathway, a Communitarian version of the Final Solution.

Then comes the final slide.

Which is supposed to extort a chuckle from the gathered throng of healthcare professionals who haven't already dozed off!

This is sick...

According to a LCP Symptom Control Algorithm chart, Medicines for symptom control will only be given  when needed, following an assessment, and at the right time and just enough and no more than is needed to relieve the symptom.

Anticipatory prescribing is recommended - whether the symptom is present or not, prescribe in any case - but it is given prn, as required. 

In the Newsletter, the Macmillan GPs are rather more gung ho - "Good pain relief requires regular dosing rather than a vague direction 'as required'."

If there is not consensus on what are the LCP protocols how can there be meaningful training?

Meanwhile, the National Council for Palliative Care is going gung ho in discussions with NICE on the use of strong opioids.

From the NCPC Report and Financial Statements 31 March 2012 -

There were two significant NICE consultations during the year, on an End of Life Care Quality Standard and on the use of strong opioids. Our consultation responses were informed by extensive feedback from our working groups as well as by people with personal experience of end of life care,and many of our key recommendations were accepted.

End of life discussion is intended to gear down expectation. End of life discussion is intended to gear down perception to see the cup half empty rather than half full. End of life discussion is intended to gear the mind into seeing dying as a positive life option and to perceive the moment to be gone.

From the Newsletter - "Discuss with family and friends how to get care and help at different times. Specifically advise that calling 999 is very seldom appropriate and may result in resuscitation, transfer and admission."

We don't want those readmissions; they cost money.

1 comment:

  1. Minimum of 4-5 liters of drinking water is necessary for an average person to keep him healthy and active.

    Nutrition and Hydration week 2014