Monday, 18 February 2013

Liverpool Care Pathway - The Morphine Ruger

The End of Life Care Programme has as its purpose to identify, in an 'if the hat fits wear it' fashion, suitable candidates for the programme to gear down expectations to more readily accept palliative rather than curative options, to groom the failing in health to accept finality rather than hope.

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 more 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.

Interestingly, Mr. Lamb is one of two DoH ministers known to be supportive of euthanasia reform, the other being Anna Soubry. Read this BBC News report.
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. It is asserted: "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.

What advice there is on morphine is diverse and differing, as already shown.

As this Bristol Palliative Care Collaborative formulary shows, when administering the LCP at home or in hospice, there is NO UPPER LIMIT on the amount of morphine that can be given in conjunction with midazolam - no upper limit whatsoever...

Anticipatory prescribing for end of life symptoms in the community

The LCP permits doctors and nurse consultants to prescribe morphine to anyone who is in the 'last 12 months of their life' - in their opinion. These drugs are left at their homes in what are called 'Just In Case' boxes.

There is no antidote to morphine (Naxolone) included in these 'Just In Case' boxes. If there is an adverse reaction and  breathing problems develop, they are doomed. Furthermore, the quantities of morphine in these 'anticipatory prescribing' boxes exceed the amounts of morphine which Dame Janet Smith (who chaired the Shipman Inquiry ) took as being a dose capable of being used to commit murder.

In 'palliative care' environments, nurses are allowed to prescribe what are called 'unlicensed' doses (i.e. doses that are ABOVE the recommended safety limits that have been agreed within the medical and pharmaceutical research professions). The British National Formulary warning about morphine is (i) it should not be given with another CNS depressant unless you are being cared for in an environment with resuscitation equipment available, and (ii) you should have arterial blood gases taken to check your blood is not accumulating CO2. The LCP does not allow 'unnecessary tests' and the charts would act as evidence you were effectively suffocating!
Palliative care drugs are all prescribed 'prn' (i.e. the nurse or doctor can prescribe as much as they feel you require, using their 'clinical judgement') All a busy district nurse has to do to avoid having to call round on a bank holiday is say he/she 'thought you were in great pain'..and they'd get away with it. That statement, in the context of the reported killing wards that are our hospitals, is not at all as outrageous as it sounds.

This is from
“The simple answer is that morphine and other opiates can hasten death in anyone, but particularly children or the elderly.
Opiates are very effective pain killers, but as a consequence can also cause sedation and reduce breathing. This combination can be lead to death, and is particularly important when given to a patient who already has compromised respiration such as through a chest infection.”

As mentioned here, Rev. Alan Billings, Director of the Centre for Ethics and Religion at Lancaster University, has commented that morphine frequently ends the lives of terminally ill people, and causes sedation when given in doses necessary to relieve pain.

However, the same article disagrees and claims that "morphine is a safe and effective pain killer and should never cause death, according to a major new study which explodes the myth that doctors use the drug to hasten the end for terminally ill patients." This claim is made in reference to a study, Respiratory function during parenteral opioid titration for cancer pain, by Estfan and Colleagues at the Taussig Cancer Clinic in Cleveland, USA, which was published in the leading medical journal, Palliative Medicine, and involved 30 patients with severe cancer pain.

However, the paper by Estefan does not address the use of morphine in conjunction with other Central Nervous System depressants, like Midazolam - which is co-administered for symptoms on the LCP. The paper must be discounted as a parameter for morphine use in the LCP, therefore.

The abstract of this paper refers to 30 patients who completed the study, but only 29 are reported. Did the study have its outcome set such that all contrary results would be excluded?

The original research paper shows that 149 patients took part in this study. Reading the paper, rather than the abstract, it says that 120 patients were initially involved in the study, but the vast majority had to be withdrawn because morphine caused them to hallucinate.

The above Bristol Palliative Care Collaborative mentions hallucinations or confusion under '3. Agitation' in the symptom list...

The following conversation on Twitter was observed on Valentines day. It went like this -
Pharmacy Dispenser: "Received rx for midazolam 10mg/2ml; 2.5mg - 5mg prn for bubbliness .... #seriously?"
Hospital Pharmacist: "palliative?"
Pharmacy Dispenser: "what gave it away? ... The fact that they prefer care home residents to be comatose?!"
Hospital Pharmacist: "no: a typical dose in palliative care "anticipatory med" supplied at discharge to those on LCP for DNs/nurses at NH to give."
The LCP (mark 12) is current and complies with provisions of the Mental Capacity Act in the regard of capacity and informed consent. LCP (mark 11) was current until 2010 when version 12 was published. 

This is a Symposium on Care of Dying People in Hospital
[extract copied for purposes of literary comment] -

Current practice

Evidence for diagnosing dying is drawn from a combination
of observational data and expert opinion.
Traditional signs associated with approaching death
include deteriorating performance status, decreasing
or fluctuating conscious level, withdrawal, weakness,
reduced oral intake and difficulty with oral medications
(Twycross and Wilcock, 2001; F├╝rst and Doyle,
2005). The significance of these signs, however, may vary
according to underlying diagnosis. In addition, each of
them may vary during the course of an acute or chronic
illness, and so must be interpreted in light of the overall
clinical picture of the patient.

The Liverpool Care of the Dying Pathway version 11
(Marie Curie Palliative Care Institute Liverpool, 2005)
originally drew on these factors to highlight an appropriate
time to commence the pathway, using the presence of
a number of clinical signs. While these were not characterized
as ‘signs of approaching death’ (the documentation
suggested they be considered only when ‘the multiprofessional
team has agreed that the patient is dying’ and
all potentially reversible factors had been considered),
they might be inappropriately interpreted as such; this
led to criticism in the press (Devlin, 2009).

The most recent version (version 12) of the Liverpool
Care Pathway has a different supported decision process,
placing greater emphasis on team decision making and
regular review, and removing any specified signs that may
be misapplied (Marie Curie Palliative Care Institute
Liverpool, 2009). Instead, the decision-making process
begins with the statement ‘The team believe the patient
is dying’, and prompts a reassessment at least every
3 days. While this does not include specific guidance on
how dying is recognized, it clearly addresses the criticisms
of ‘tick-box medicine’ and allows scope for careful, clinical
assessment and review.
[Copyright of British Journal of Hospital Medicine (17508460) 
is the property of Mark Allen Publishing Ltd]

Problems arise because this paper shows how the wording of LCP (mark 11) differed from the wording of LCP (mark 12). The clinical signs it used are also just signs of reversible problems in someone who is critically ill.
 Rolled out in a hospice situation of patients diagnosed already with a terminal condition such as cancer is precarious enough, but in any other situation, where no terminal condition such as cancer has been diagnosed and no such life-limiting prognosis made - in fact, an actual 'diagnosis' of dying is being made and acted upon – this may be viewed as potentially catastrophic...

..... and ridiculously negligent therefore to roll out across ALL specialities with scant or inappropriate training, or none at all, or just 'for fun and free' as is reported on page 8 of the above-mentioned Newsletter.
Dr. Bee Wee has blamed inadequate training for the apparent inadequacies of the LCP. Who is in charge of that training, at least, the e-training mentioned in the above-mentioned Newsletter? Dr. Bee Wee. "The project has been developed by e-Learning for Healthcare (e-LFH) and the Association for Palliative Medicine and is led by the National End of Life Care Programme and the Department of Health." Anyone else want to own up?

This is Ministry of Ethics -


(Except under special circumstances, for example for serious mental illness under the Mental Health Act 1987/2007 or certain communicable diseases under the Public Health [Control of Diseases] Act 1984).
Obtaining informed consent is a legal and ethical necessity before treating a patient. It derives from the principle of autonomy; one of the 4 pillars of medical ethics: (Autonomy, Beneficence, Non-maleficence and Equality - as described by Beauchamp and Childress1). Touching/treating someone without permission could be considered assault or battery under criminal law and civil law, even if the person was helped by your actions.
For consent to be valid it must be informed consent. For this to be the case it must be:
o  Given voluntarily (with no coercion or deceit)
o  Given by an individual who has capacity
o  Given by an individual who has been fully informed about the issue.
Consent can be written, verbal or non-verbal/impliedA written consent form is not the actual consent itself, but evidence that consent has been given (most forms include sections to record the important aspects of the procedure the patient has been informed of). Implied consent is an action such as offering your arm for blood samples. It can be unreliable as a patient may argue that their actions were misunderstood and they did not actually wish to consent.

Problems arise because, after the code of conduct accompanying the Mental Capacity Act 2005 became law (Oct 2007), it became a criminal offence to take consent without a test of the patients' competency to give it. However, this wasn't added to the LCP until version 12 was published in 2010.

Alarm bells! Are we looking at tens of thousands of cases of wilful neglect, which is a criminal offence?

My dear mum "consented" to morphine. This 'consent' was obtained by the unique power or ability to discern a nuance of voice or facial expression by those skilled and experienced to make such interpretations of nuance of voice or facial expression!

Was there a "test of competency to give consent" made? Well, this was in July of 2007, so the trusty judgement of these 'wise women' was quite sufficient.

And the review...

Were this a trial in a court of law and these "nine good men and true" sat upon the jury, the jury would be dismissed for possessing their own agendas, self-interests and interests in outcome of the trial.

Were we talking of an aircraft which has experienced viability issues, it would not be just the aircraft involved that would be grounded; the entire fleet would be grounded until such time as an inquiry is completed and answers determined and causes addressed. why is the LCP (mark 12) still up and running and out there doing its worst?
The LCP is a killer.

"For a backup, this professional chose the LCP. It is a reliable, lightweight and effective tool. The LCP has a range and performance that encourages confidence."

This is the Ruger LCP:

The Ruger "LCP" or Lightweight Compact Pistol... 

"Guns are tools. Tools can fail..."

See -

The die are loaded and so is the gun. They're ready and armed with a loaded pistol to your head...

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