Wednesday, 13 February 2013

Liverpool Care Pathway - The Action Plan

The LCP has crept into every area, even those areas where it would appear to have no place or purpose to be. LIVING AND DYING WELL is a national Action Plan for palliative and end of life care in Scotland.

At page 23 -
Example 13 – Older People’s services in Lanarkshire.
The emphasis is on holistic and person centred care which balances rehabilitation and enablement with an anticipatory and palliative approach in the care of frail older people with complex and end of life care needs.This work includes: roll out of Liverpool Care Pathway (LCP) within Older People’s directorate assessment, rehabilitation and continuing care wards.

A rehabilitation ward...

To that, this comment refers: 
"This makes perfect sense to me now. My Nan was admitted for what she was told was going to be physio & rehabilitation (definition "To restore to good health or useful life"), only to instead be put on (what we discovered afterwards was) the Liverpool Care Pathway, which led to her demise in just 3 days after entering that godforsaken hospital."

Example 7, includes a focus on preventing inappropriate admissions and facilitating discharges to or from hospitals.

In other words, ensuring that palliative rather than curative options are pursued.

The June 2010 Macmillan End of Life Care Newsletter shares the National End of Life Care Programme logo and is published by NHS.

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."

Everywhere, in regard to healthcare, you will hear this mantra -
Affordable, Sustainable.
Community-Based Care Strategies are aiming to cut those costly hospital readmissions.

This report published last month says that "local commissioners and providers will work together to transform the local older people’s services to reduce acute admissions by one third and to redesign outpatient services to reduce volumes by around 6% per annum for three years."

Psychometric testing has been introduced to encourage nurses to "consider approaching any patient who the nurse considers to be in the last months of their illness, regardless of diagnosis, and including the frail elderly."
This Action Plan uses the concepts of assessment and review, planning and delivery of care, and of communication and information sharing as a framework to support a person centred approach to delivering consistent palliative and end of life care in Scotland.
Person centred - another mantra. In the context of psychometrics, that is worrying.

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.

NHS Boards, through palliative care networks and CHPs, should ensure thatrecognised tools/triggers to support the identification of palliative and end of life care needs of patients diagnosed with a progressive, life-limiting or incurable condition and the needs of their carers are used across all care settings by 2010.
NHS Boards, through palliative care networks and CHPs, should ensure that patients identified with palliative and end of life care needs are appropriately assessed and reviewed in all care settings using recognised tools currently available.
The National Clinical Lead for Palliative Care, in partnership with key stakeholders including diverse patient representation will set up a short-life working group (2008 – 2010) to consider Audit Scotland recommendations regarding standards for palliative and end of life care
All is in place.
19. A theoretical awareness of the three main disease trajectories identified can help with recognition of such triggers. The relatively predictable cancer trajectory of diagnosis, treatment, possible remission and final deterioration is widely understood, and appropriate triggers for assessment and review of cancer patients and their carers already generally recognised. In the organ failure trajectory, critical events such as the frequent unscheduled hospital admissions and readmissions experienced in advanced heart failure or chronic obstructive pulmonary disease (COPD) may be seen as a trigger for further holistic assessment and the development of an appropriate care plan for the next phase of the patient’s journey. In the prolonged frailty/dementia trajectory, key events indicating the need for further comprehensive assessment, including consideration of palliative and end of life care needs, might include significant deterioration in function, increased need for carer support, referral for specialist advice, or admission to a care home.
The tools are prepared to permit the selection process to proceed.

The pie chart and flow chart is employed to illustrate and impress. There is a schematic diagram adapted, with permission, from Rand Corp. This formalises the palliative options. It consists of two diagrams labelled Old Concept and Better Concept. In the latter, a new parameter of 'time' is introduced, presenting a pathway of finite proportion and presenting progressively limiting curative and certain palliative potential.

There is a further schematic of illness trajectories with a like source citation.

Perhaps it was sourced from here -

JBI (Joanna Briggs Institute) is a research and development organisation based at Adelaide University, South Australia -
"The Institute collaborates internationally with over 70 entities across the world. The Institute and its collaborating entities promote and support the synthesis, transfer and utilisation of evidence through identifying feasible, appropriate, meaningful and effective healthcare practices to assist in the improvement of healthcare outcomes globally. 
"We provide you with the best available evidence to inform your clinical decision-making at the point of care."

JBI provided an evaluation of the role and value of a national office of coordination for Liverpool Care Pathway implementation in New Zealand. This can be found on Pubmed.

In writing an authoritative work, nothing lends it more authority than to cite or to name-drop a recognised authoritative and respected body.

In the Introduction, The Action Plan cites the World Health Organization (WHO) -

1. The World Health Organization (WHO) defined palliative care in 2004 
as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. In 2004 WHO recommended that planning for care at the end of life should be responsive to patient choice regarding place of care and place of death.

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.

This is edited by 
Sue Hall, Hristina Petkova, Agis D. Tsouros, 
Massimo Costantini and Irene J. Higginson

Citations are further made in the body of the text.

Some of these names are known and keep cropping up. Why shouldn't they? This is their sphere of speciality. Let's look at one of these.

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, however, 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 EnglandJournal 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.

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.

The WHO publication expresses that same clear concern that is expressed in the Action Plan; that there is a growing ageing population. Action Plan presents a population pyramid for 1981 and a projected pyramid for 2031. It is quite plain and evident that it is a concern for these demographic factors that is driving the EoLC Programme, not care.

That is clear. That is worrying.

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