Monday 11 February 2013

Liverpool Care Pathway - The Big Question


The Big Questions - Is the NHS cutting lives short? is covered in the final 20 minutes of the programme. Five days left to view.

This is The Big Questions -

The Big Questions

From Michaelston Community College in Cardiff, Nicky Campbell asks:
Is the NHS cutting lives short?

Baroness Finlay, a palliative care specialist; Dr Richard Hain, consultant in paediatric palliative medicine; gastroenterologist Dr Philip Howard; oncologist Dr Mark Glaser; Jackie Leotardi.



Transcription follows:



Nicky Campbell

Most of us prefer not to think too much about dying; it’s not really something we can plan for but we all hope for a good death, pain-free, surrounded by our loved ones, at home and in peace. But more than half of us will die on a busy hospital ward and that’s why the Liverpool Care Pathway was developed to try and make each of those deaths as pain-free and peaceful as possible.

Some families and doctors now fear that putting a patient on the Liverpool care Pathway has itself become a death sentence ruling out the chance of recovery. Is the NHS cutting lives short?

Em, Dr. Philip Howard. Em, there’s been quite a media furore about this, something of a media hysteria about it. The Daily Mail has been talking about it a lot. Em, it’s not about not prolonging a life; it’s about not prolonging a life unnecessarily, isn’t it? I mean, do you approve in principle of the Liverpool Care Pathway?

Dr. Philip Howard –

I think one of the problems with the Liverpool Care Pathway is it’s predicated on a false premise, namely that you can accurately diagnose death; you can make an accurate prognosis as to when that person is going to die, within the next few hours or days. And there’s no scientific evidence that we can do that. And I know of no calibration tools that we can use to say just how accurately we can make that prognosis. That’s the danger. Now, if you then sedate the patient, stop observations, stop interventions, and stop food and fluids, the patient must die. Whether or not they would have died anyway, they must die if you adopt that regime in full.

Nicky Campbell

Baroness Finlay, can we have full confidence that, em, given the perceived crisis in care - it’s been a very difficult week for the NHS – that this is being ethically and appropriately applied?

Baroness Finlay –

Can I pick up the point, first of all, about prognosis…

Nicky Campbell

Please do.

Baroness Finlay -

The Royal College of GPs in evidence to the select committee I was on said, and I quote, it’s possible to make reasonably accurate prognoses of death within minutes, hours, or a few days. When this stretches to months, then the scope for error can extend into years. The thing is that there is no absolute way of predicting what’s going to happen anywhere. It’s on probabilities. Now, when somebody looks as if they’re dying and you have done all you can to exclude all reversible causes, then, whatever you do, you must go back and review and review and review. Good medicine is based on evidence, on going back and analysing what you see before you.

Nicky Campbell –

And what about a junior doctor, weekend staffing, a busy ward, you know; if it’s down to good people who are not under pressure, who are not stressed, fine, but is that always the case?

Baroness Finlay -

I certainly think that the evidence that’s been coming forward – let’s look at evidence – is that there seems to have been a problem in some cases and there is now an inquiry set up under Baroness Neuberger.  I think that she needs to be able to access all the evidence, she needs to be able to look at all the cases and she needs to be able to conduct her inquiry independently, impartially, and look at where the problems lie, where there are problems and, much more importantly, two, is what the solutions to those problems are.

Nicky Campbell –

This… You see, the people here and at home… If there’s a problem with the application, that’s… Jackie…


Jackie Leotardi - 

We, we would argue that, of course, there’s a case for high quality palliative care in hospitals and in the home but, when that’s rolled out indiscriminately in the NHS, it becomes very, very dangerous. My father was admitted to hospital on a Friday evening, parked on a ward all weekend. We begged them to do a CT scan. They kept saying, oh, we’ll have to see, we’ll have to see, we’ll have to see. We got the consultant brought down to his bed; she still refused to do a CT scan. On the Tuesday morning, they called us in. Oh, it’s too late now, he’s too poorly. We were given a definitive diagnosis of perforation. We said, how can you say that based on inconclusive x-rays? Oh, we’re sure it’s a perforation. He was put on the Liverpool Care Pathway and died. At the post mortem , it was found that he actually had a pulmonary embolism.

Nicky Campbell –

It was a misdiagnosis.

Jackie Leotardi - 

Yes. It was a total misdiagnosis. The reason we’re here is because elderly care in the NHS is appalling.

Applause.

Baroness Finlay -

May I say firstly, I’m not here to defend the whole NHS; I don’t know the ins and outs of the tragedy of your father’s case.

Jackie Leotardi - 

Exactly.

Baroness Finlay -

And I’m not; I can’t comment on that, but there certainly would appear to have been a misdiagnosis. The difficulty in this discussion is, did the Liverpool Care Pathway itself prevent people reviewing that diagnosis, or was the failure at a different point earlier, and a failure of care?

Daughter of Jackie Leotardi - 

The problem is it wasn't just a misdiagnosis; the fact is they didn't do any investigation into what he had. So, unfortunately, with a system like this, with the best intentions in the world, people will fall through the cracks like our granddad, and even if one person falls through the cracks, for me, that is wrong.

Applause.

Baroness Finlay -

I would certainly, I would certainly not condone anyone falling through the cracks. The whole… of the

Nicky Campbell –

So this goes back to my first question, doesn’t it? Given, you know, given the current problems, the current stresses, the future pressures, reorganisation, do we have… Do you have the utmost, as much as you can, confidence that this is being used appropriately and ethically and responsibly applied?

Baroness Finlay -

Of course I couldn’t say that I have a 100% confidence. We have an inquiry. I have been arguing for an inquiry. I’ve supported the setting up of an inquiry. And we need to have it. It needs to go and look in detail. Is the problem with the documentation itself; is the problem with the way it’s being rolled out; is the problem with what’s been happening actually at the bedside?

Jackie Leotardi - 

Financial incentives. Hospitals have been paid. We saw last week with the Francis inquiry about the problem; about a target-driven NHS. Financial incentives have been paid to hospitals, certain hospitals that are now being investigated for their mortality rates…

Nicky Campbell –

30 million…

Jackie Leotardi - 

Yes. One hospital was paid £308,000 for reaching targets for putting people on what is basically a euthanasia programme. Baroness, it is euthanasia.

Baroness Finlay -

It… No, euthanasia is about intent. The Liverpool Care Pathway doesn’t intend to kill people. It intends to improve the care when people are inevitably dying. That’s quite different.

Daughter of Jackie Leotardi - 

But it doesn’t work in practice…

Nicky Campbell intervenes and indicates –

Richard. Richard.


Dr. Richard Hain –

In… In your interview with The Gazette, you finish your interview accepting…

Nicky Campbell –

What Gazette is that…?

Dr. Richard Hain –

I can’t remember the name of it. Your local Gazette.

Nicky Campbell –

Okay…

Dr. Richard Hain –

You made the point that it’s not that the Liverpool Care Pathway is bad in itself, it’s that it can be badly used. I’m paraphrasing, but that was…

Jackie Leotardi - 

That’s right. It’s abused in the NHS. (pauses)

Dr. Richard Hain –

And I think that’s the distinction we …
.
Nicky Campbell intervenes -

So… Richard. So, the principle of it  is…

Dr. Richard Hain –

The principle of is that there is a point in the life of a patient when we know when… when they are going to die. We may not know it with absolute certainty. We’ve already talked about how human beings find certainty desirable but we can’t always have it. If we wait until we are certain, we miss the chance to care for them over that time.

Nicky Campbell –

So, it’s about not prolonging a life unnecessarily.

Dr. Richard Hain –

Not prolonging or hastening it.

Nicky Campbell intervenes and indicates –

Dr. Haboubi.

Dr.Nadim Haboubi -


Em, em, em. I’m a physician and I look after acutely ill people. And we do, occasionally, put patient – and this is not frequent, you must understand that – on the Care Pathway. We agonise on these decision. We consult with nurses junior, senior doctors...

Nicky Campbell –

Family.

Dr.Nadim Haboubi - 
Family, of course. You can’t put a patient on a care pathway unless you consult the family

(Intervening voices) - 

And yet very often does 

Jackie Leotardi - 

Very often, there is no consent given

Nicky Campbell –

Were you consulted?

We were told that it was inoperable and that was what they were going to do. Beforehand, we were fighting for investigations...

Nicky Campbell – (Talks over)

So you trusted… You trusted

Jackie Leotardi - 

To be taken.

 Nicky Campbell – 


You trusted their analysis, their diagnosis.

Jackie Leotardi - 

Well, we didn’t know, but what, what could we do, dial 999 and call the police? But I know a lot of people who weren’t consulted. Their consent wasn’t sought from the relatives; consent wasn’t sought from the patients.

Nicky Campbell – 

Julia.


Julia Manning - 

That is absolutely wrong. I was not behind the development of the Liverpool Care Pathway which was developed at Liverpool with Marie Curie cancer. It was very much about having the conversation around dying well, and just as an expectant mother has a birth plan, we should all expect to have a death plan, how we want to die, where we want to die, what kind of interventions, and to not have that conversation was absolutely wrong and, you know, you were betrayed in that I just want to come to come to another point about the financial incentives. I think it’s totally wrong that hospitals are paid to put people on this pathway. The money should go…

Applause.

Julia Manning - 

The money should go into training palliative care professionals and it should also, as we’ve heard with the Francis report and one of the first suggestions is that we need many more professionals who are trained in care for older people.

Nicky Campbell – 

Is this another example of the target driven culture, Baroness Finlay?

Nicky Campbell, indicates Dr. Richard Hain –

I see you’re nodding…

Baroness Finlay -

I… I think there’s areal danger in trying to put simplistic targets around healthcare which is incredibly complex

Nicky Campbell –

And nuanced…

Baroness Finlay -

The absolute critical thing is that, whenever you've got a patient in front of you, you must go back and review. You must rethink what you write. Is there something else going on? Is there something actually reversible?

Nicky Campbell – 

Yes. So, that’s it. Richard, how often - and I know this is an interest area of yours – how often, once somebody is on the Liverpool Care pathway, has somebody been taken off it because signs of recovery have been…

Dr. Richard Hain –

I need to be clear, I do paediatric palliative care and we don’t use the Liverpool Care Pathway in children. But the principal that you’re asking, how often do we go back and review? We review all the time. Eh. Every minute of every day, we… We would see a patient every day and I think this issue of… em, it’s not so much a question of consent to go on the Pathway, it’s the fact that the conversation needs to take place. It was designed to facilitate that kind of communication, not to replace it. And I think it goes back to an earlier comment, because it’s about individuality of the patient we’re dealing with rather than the NHS trying to shape itself through defining targets.

Baroness Finlay -

Can.. Can I just say, when you go back and review, about 3% of times, you find that, actually, you were wrong. The person isn’t dying. They’re actually… They’ve improved because you’ve stopped whatever treatments you were doing that were making them worse than they felt… because that’s the nature of medicine.

(A converse of voices)

Nicky Campbell – 

Is it the case… Is it under constant review when somebody’s on the Pathway?

Dr. Philip Howard –

One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.

Pause.

Nicky Campbell – 

A lady… 

Nicky Campbell (indicates) - 

You put your hand up a few minutes ago. I don’t know if your point is still relevant but please make it. Go on.

Lady -

What’s particularly worrying is that the vulnerable are the ones who are in most danger. How about the people who don’t have families

Voices in agreement. Applause.

Lady -

Who may not be in the right mental capacity to understand what is happening around them. Yet again, we are seeing in this society that the most vulnerable are being put at risk, you know, from winter fuel payments wanting to be kept down, to bedroom tax… Yet again, we are targeting the vulnerable and I think that this Liverpool Care Pathway shouldn't be allowed if you can’t 100% guarantee that there aren't risks like this happening.

Nicky Campbell – 


Jackie

Jackie Leotardi - 

The people I know… The people I know who have come off the Pathway have had families who have been strong enough and confident enough to defy the doctors and nurses. An old gentleman we know, after three days, he said, that’s it, I'm feeding my dad; I'm giving him some porage, I'm giving him a drink; that old man, at 91 years of age, went home from hospital on Friday. But if his son hadn't had the guts to stand up to the doctors and nurses, he would be dead by now.

Nicky Campbell – 

So, Richard, is…

Jackie Leotardi - 

And that’s what’s happening today in the NHS.

Nicky Campbell – 

Is there a danger, then, that it becomes a matter of resources? 

Dr. Richard Hain –

There is a danger. But that’s a misapplication of a good Pathway, rather than because the pathway itself  is wrong.

Nicky Campbell – 

Extol the virtues of the Pathway if there’s anyone listening who’s thinking, 'oh my goodness'.

Dr. Richard Hain –

Because I think it’s more difficult for doctors to do nothing than it is for them to do something and there are times when to do nothing interventionist is the right thing to do for people. And they need some help in doing that nothing and doing it well. And the Liverpool Care Pathway provides the support for them to make those good decisions. Em. That doesn’t mean that it’s always implemented properly and I think what we’ve heard are a number of examples where it has been implemented poorly.

Jackie Leotardi - 

The paperwork is sloppy. It just has to be signed by one doctor and a nurse. My father’s paperwork was sloppy. The space for diagnosis is tiny.

Nicky Campbell (indicates) - 

The lady there. Good Morning

Lady - 

Can I just speak up for doctors and nurses because any doctor and nurse I’ve ever met in the NHS;

Applause.

Lady - 

they’re not angels of death that I feel people are painting them out to be here. They care very much and they do have the patient’s best interests at heart, from my experience is.

Applause.


Nicky Campbell (indicates) - 

Yes.

Christina Biggs -

 I . I think with death, we… It’s just that people don’t want to acknowledge it might be happening now, and they might actually be on the way out. So, I think there is an aspect where we, maybe, sort of… We’re so afraid of death; we should be fighting franticly. And there’s the other side of it where we just see this patient lying there as someone we want to get out of there, you know. So, em, I certainly had; my father’s cousin, he’s got Alzheimer’s very, very badly and… I meant to go and see her for years and years and years and, about two weeks ago, I went to see her and she was in a, you know, very comatose state, in the bed, all scrunched up and she was my father’s cousin. And I was so glad to see her and she had Alzheimer’s, but she recognised, well, not my name or her husband’s name, but she did know her sister’s name and her cousin’s name, and we did have this conversation. Thankyou for everything you've done in the past. And I think, maybe people… Doctors have just got to remember that these people are grandparents, aunts, uncles, and it’s this huge human thing about seeing people and not just either cutting it short or dragging it out as you say, but it’s a human institution, it’s – not institution -  it’s a really important..

Nicky Campbell – 

And that, in the vast majority of cases, is what happens isn’t it?

Dr. Philip Howard –

Yes, it is. And I think it’s a pity. We've had palliative care in this country for 35 to 40 years. We pioneered good care for the dying in this country through the Hospice movement. That was a quiet revolution in medicine and we’re very proud of it and it’s still applied widely. I think the tragedy is that we’ve got a problem. We never had this sort of controversy that we’re seeing with the Liverpool Care Pathway over the Hospice movement. Walk down any High Street and you will see charity shops for Hospices. There’s a tremendous amount of support and rightly, in this country, for the Hospice movement, for hospices, for good care. And I entirely agree with Baroness Finlay that we must have a proper review of this. Em, it is quite clear that there is a genuine concern about the way palliative care is happening in this country. And it is going to have to be a proper and thorough-going investigation as to what’s going on. And the sense that I get from relatives – and Jackie has just illustrated this very nicely – is that relatives and the public at large want good palliative care. Everybody is pushing from the same side. They want doctors and nurses and the system to work well for those that are dying. And that must happen.

Applause.

Nicky Campbell (addresses Baroness Finlay) - 

Can I just.. You've only got a few seconds. This has been in place for quite some time, hasn't it?

Baroness Finlay -

Right. If I may pick up on the comment that was made. Doctors and nurses, by and large, desperately want to do what’s right by their patient. They don’t get it right all the time. We've been trying to drive up standards of care. We just have to be careful we don’t throw the baby out with the bath water.

Programme Credits....




The unanswered question:

Dr. Philip Howard –

One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.


Comment of concern:

Dr. Richard Hain –

… em, it’s not so much a question of consent to go on the Pathway, it’s the fact that the conversation needs to take place. It was designed to facilitate that kind of communication, not to replace it.

Where the patient lacks capacity, the Mental Capacity Act enables the medical team to act in the patient's "best interests". Consent  is not required. In such cases, the Data Protection Act, also, might exclude relatives/next of kin being party to such a decision being taken. Recent observations by political personalities that this should be otherwise are at variance with this legislation.

This is a legal quagmire.

18 comments:

  1. It is my experience in 5 years of caring for patients as a doctor on NHS acute medical wards that the vast majority of those deemed suitable for the LCP are unable to give consent. The reason for this is simple - they are, by definition, dying and too ill to do so.

    I believe it is vital that doctors retain the ability to palliate people in their best interests when they cannot give consent. You would not argue that we should not treat seriously ill people who cannot give consent in any other circumstance. Remove the ability of doctors to administer pain relief and prioritise symptom relief in dying people (and this is all that the LCP is designed to do, despite the hysteria in the press), and the result will only be more people dying in pain.

    I feel so passionately about this that I have started a site of my own to try and clarify what the LCP is.

    I have also discussed the BBC's Big Questions - see http://lcpfacts.co.uk/lcp-discussed-on-bbc-the-big-questions/.

    ReplyDelete
    Replies
    1. What is your GMC Registration Number? And what is your specialty?


      Your "experience on acute medical wards" (not specified) may differ significantly from the experience of practitioners using it in other healthcare settings. The period of 'the past 5 years' covers both v.12 and its forerunner (the now withdrawn v.8): the topic of discussion in both cases here was v.8.

      I note that you are using the Marie Curie LCP logo on your website: can you confirm you have been authorised to use this by MCPCIL, and that the rather confused 'explanation' of the LCP that is already posted there for all to see on the www. has been checked and passed as compliant by them ?

      Thank you.

      Delete
    2. This 'doctor' has a site that reinforces the very strong argument that there is no evidence base for this care pathway, or the drugs the LCP recommends (the assertion it is not a 'treatment' is incorrect-this practitioner is demonstrably wrong on that):

      Under the 'Evidence' tab, he/she provides a link to the evidence base for using the LCP. It provides a link to the Cochrane Library at

      The conclusion drawn by the authors of this paper was as follows:

      "Authors' conclusions

      Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people."

      There is no evidence base at all!

      Delete
    3. FYI: lcpfacts.co.uk is written and edited by Dr Stewart Gibson BSc MBChB, a medical doctor training in Acute Medicine in Leeds in the UK.

      Delete
    4. He says he created this website to:
      Clarify the purpose of the LCP, by explaining what it does and does not involve, and providing an example of the pathway document.
      Review the evidence that supports the use of the LCP (and similar care pathways) in caring for dying patients.
      Encourage rational debate about how to achieve best care at the end of life.

      Can I suggest that anyone who wants example documents downloads them directly from MCPCIL, and bases 'rational debate' on their own direct experience..as even Dr. BeeWee's own Cochrane Review concedes there is no 'evidence base' apart from the lowest SIGN level (level 5 and 'expert opinion')...

      Delete
    5. Since he is flying the LCP logo on his website here , and Marie Curie Liverpool state they have signed off all documents bearing this logo (here http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/register/)

      The most ridiculous aspect of this 'pathway' are that according to this site:
      "Once registered with us you will receive a copy of the LCP that you can make your own by adding additional information. "

      ...so basically, it would be impossible to find an 'evidence base' for the LCP, as individual practitioners can add whatever they like to it.

      Pancuronium, or a swift injection of KI anyone??????

      Delete
    6. Bee Wee's publication, "How useful are systematic reviews for informing palliative care practice? Survey of 25 Cochrane systematic reviews" ....concludes there is no evidence base at all!

      "Conclusion

      Cochrane reviews in palliative care are well performed, but fail to provide good evidence for clinical practice because the primary studies are few in number, small, clinically heterogeneous, and of poor quality and external validity. They are useful in highlighting the weakness of the evidence base and problems in performing trials in palliative care. "
      http://www.biomedcentral.com/1472-684X/7/13

      Delete
  2. Hello LCP facts, it's good to see a doctor post here, thank you so much for doing so, I hope you will continue to post. Thank you for your website too, I just had a quick look and I shall certainly look at it in more detail as it looks very interesting.

    Dr Philip Howard has recently stated:

    “It is a decision with an end in view. The patient is dying. Why? Because we say they are dying. Why? Because we have decided.”

    Your response was:

    "In my opinion there are problems with this view. In predicting death, as in all areas of medicine, there is never 100% certainty. However we accept that it is often necessary to act in a patient’s best interests on the balance of probabilities. Even if it is not possible to predict the timescale of death with absolute certainty, if imminent death seems likely we have to review whether our interventions are helping the patient and how we can ease their suffering; this is all that the LCP requires us to do."


    Isn't the key issue though, as Professor Patrick Pullicino has stated, that there is no scientific basis for applying the LCP...that the LCP is based on the abandonment of science?



    ReplyDelete
  3. I've now found Professor Pullicino's speech to the Medical Ethics Alliance:

    "The dangers of abandonment of evidence based medicine in the use of the Liverpool Care pathway"

    A presentation by Professor Pullicino, professor of clinical neuroscience, university of Kent, to the Royal
    Society of Medicine.

    “Evidence-based medicine is increasingly regarded as the gold standard of clinical care. The Liverpool Care Pathway (LCP) is a pre-specified “care plan” used for patients who are judged to be “in the last hours or days of life. 29% of patients in National Health Service (NHS) hospitals currently die on the LCP.

    The median time to death on the LCP is 33 hrs. A review of the literature reveals that there are no published Criteria that can predict death within this time frame.

    The lack of an evidence-base for institution of the LCP makes it a form of assisted death rather than a care plan.

    The personal judgement of the physician and other medical team members about perceived quality of life or low likelihood of a good outcome are probably central in the decision to put a patient on the LCP.

    There are likely many patients who have been killed by the LCP who could have lived substantially longer.

    The LCP is also likely to negatively affecting doctor-patients relationships and have a negative impact on medical care, particularly of the elderly, in NHS hospitals.

    Prognosis is a statistical range of survival times based on assessing the patient’s survival by use of a previously published prognostic scale.

    Prognostication has limited accuracy. Survival is frequently over- or under-estimated and only about 25% of survival estimates are correct to within one week.[3]

    The majority of prognostication research has been done in cancer patients, with advanced disease with a high likelihood of being fatal within a relatively short time.

    Non-cancer diagnoses have a less predictable course making prognostication more difficult. Neurological
    disease has to include a separate prognostication for meaningful cognitive recovery if the patient survives, which complicates prognostication.

    Every patient is unique with personal characteristics that affect their outcome [5]

    The Palliative Prognostic Score (PaP) is the most frequently used survival score for “terminally ill” cancer patients.

    However, at least 50% of the score is subjective and based on a clinical prediction of survival and depends on the experience of the rating clinician.

    The PaP has been validated to divide patients into 3 distinct risk groups. The median survival for the groups are: 76 days, 32 days, and 14 days. The
    matching 30 day survival probabilities are 87%, 52%, and 17%.[6]

    A short term prognostication index that includes a nomogram for probability of survival at 15 days was inaccurate in up to 32% of cancer patients.[7]"


    I find the above worrying. May I ask you for your response to Professor Pullicino's points here?







    ReplyDelete
  4. My apologies, I should have stated that I am addressing my second comment above to LCP facts too.

    ReplyDelete
  5. Professor Pullicino's speech continues:

    "In this study, in a quartile (99 patients) of mean survival 10 days, over 10% survived much longer, with survival up to 200 days.

    Literature Search

    A MEDLINE search was conducted with search words “terminally ill” and “prognosis”. 405 citations were returned and these were reviewed for relevance to prognostication in a very early time frame.

    The shortest prognostication time found for a heterogeneous cancer/non-cancer population was for survival less than 1 week using the Palliative Performance Scale.[8]

    The “Last Hours or Days of Life”

    The LCP states that the patient has to be in “last hours or days of life”[1]. The median time to death on LCP was 33 (12-79) hours and was identical in the first two audits of the LCP.[9] I was not able to find any research published that addresses prognostication within this very short survival time scale.[5]

    The LCP does not in fact attempt to use any published prognostication index to determine eligibility for the pathway.

    For this reason, being “within the last
    hours of days of life” is

    a prediction not a prognostication."



    Earlier in the speech, Professor Pullicino made the following points about prediction:


    "Prediction is different from prognostication.[2] Prediction is a point estimate of survival time by a clinician.

    A prediction is at best an educated guess and often incorrect.

    The agreement between actual survival and predicted survival is poor (weighted kappa 0.36) even in terminal cancer patients.[3] Statistical models are no better at giving point estimates of survival time than clinicians.

    Using a statistical prognostic index, in 272 patients with lung cancer, 49% of clinicians’ predictions and 52% of statistical predictions were in “serious error”
    (life span overestimated by 100% or underestimated by 50%).[4]"

    ReplyDelete
  6. LCP Facts, how can doctors put patients on the LCP when, as Porfessor Pullicino establishes, there is no scientific basis for such decisions?

    ReplyDelete
  7. The fact is that the protocols of the LCP are being abused wholesale. It was originally used within the Marie Curie hospice as a means to deliver as pain free as death as possible in the last few ""HOURS"" of life. Some insane individual has grabbed the Liverpool Care Pathway and determined its use for any condition, right across the NHS and as a result the NHS, seems to have developed, what could be described as an almost fanatical defense. The NHS needs much more public accountability.

    There is no power in society to stop them, because in a doctors eyes, they have the right to declare that the patient is dying. The burden of proof falls then upon the individual, to prove that there was a misdiagnosis.

    The Liverpool Care Pathway, should not ever be used except, potentially, under the strictest of medical guidelines and protocols for diagnosis. Even then it is wide open to systemic abuse. The reason for this is that it is purely based on hypothesis, supposition and guess work at best. The Liverpool Care Pathway has no scientific or medical basis. In fact it is nothing more than a lottery and that is what the lives of our elderly and our loved one's have come down to.

    The Liverpool Care Pathway, is not safe to be used it is as simple as that.

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  8. The public must be made aware of the dangers of the Liverpool Care Pathway, only then will they be able to make an informed choice and keep a close watch on the public. I have no doubt at all, that there will be many more victims who will be mistakenly placed on this.

    To all intents and purposes, it is murder!

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  9. Baroness Finlay says:
    "I certainly think that the evidence that’s been coming forward – let’s look at evidence – is that there seems to have been a problem in some cases and there is now an inquiry set up under Baroness Neuberger. I think that she needs to be able to access all the evidence, she needs to be able to look at all the cases and she needs to be able to conduct her inquiry independently, impartially, and look at where the problems lie, where there are problems and, much more importantly, two, is what the solutions to those problems are. "

    Since it is obvious that the cohort operating from the Facebook page have already submitted bogus 'evidence', and so many of the affected families have withdrawn from the Kangaroo Court - the LCP is really nothing more than a dead horse - its only people on 'a good earner' from it who are 'flogging it' (literally, they own and sell it abroad!).

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  10. Here's my comment on Dr. Stewart Gibson's LCP Facts Blog:

    Jackie Leotardi 13 February, 2013 at 8:20 pm

    I do not wish to dwell on the details of my father’s case, but in view of the reference in your blog to the newspaper article, I think it is important to stress that it was an inaccuracy on the newspaper’s part to report that my father appeared to be in pain. The “initial assessment” on his LCP documentation reports (correctly) that he was NOT in pain, NOT agitated and CONSCIOUS. It also records that he had no nausea / vomiting. (Incidentally, he had an existing PEG tube, fitted a year earlier when his swallow was weak during infection which he subsequently hadn’t needed, but which he had kept left in as a standby, fully functional and flushed out for emergencies such as this, so risk of aspiration was reduced to a minimum.)

    The debate on Sunday was specifically covering the use of the LCP in an NHS hospital setting. My opinion is that in an NHS acute hospital setting, the requirement to consider whether there is a “potentially reversible cause for the patient’s condition” is frequently ignored. This is one of the many examples of abuse of LCP protocol.

    Supporters of the LCP on websites usually try to restrict the argument over its use in NHS hospitals to a narrowly confined field of when the LCP protocol has been “correctly” applied – they blithely dismiss the horror stories of relatives’ families as isolated incidents of “bad practice”. LCP supporters invariably start their posts by saying: “If the LCP is used correctly….” or “When staff are trained to use the LCP properly, then…..” If is almost as if they want to say that the failings reported “don’t count” because they are merely examples of when the LCP wasn’t used properly.

    They pay scant regard to the question of how abuse of the LCP can be prevented in NHS hospitals, despite the news that following the Mid-Staffs inquiry a further 14 hospitals are being investigated because of worryingly high mortality rates. They side-step the issue of overwhelming evidence of widespread LCP abuse and instead conjure up an NHS utopian fantasy land, where the LCP is scrupulously applied and all patients on it are painstakingly reviewed every 4 hours.

    Stewart, what do you suggest should be done to ensure that abuse of the LCP never takes place in an NHS hospital? What deterrents should be put in place?

    Personally, I believe it is impossible to eliminate abuse of the LCP. It is flawed because it puts far too much power in the hands of one doctor and one nurse.

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  11. I so agree with you here...but since hardly ANY of the deterrents recommended by a judge were put in place after the Howard Shipman trial, I don't see any would work, apart from 100% honesty about the real function of 'palliative care' and of a hospice...any medical practitioner who couldn't treat nausea, vomiting, pain, agitation or 'respiratory secretions' before it was rolled out across the NHS was clearly too busy to read the British National Formulary.

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