Friday, 19 April 2013

Liverpool Care Pathway - Downsizing

Downsizing healthcare and seeing the glass half-empty. It's all about rationing scarce care resources and managing budgets.
Tell me about it...

Don Berwick, newly proclaimed hero of the LCP Red Guards!

Don Berwick, newly acclaimed saviour of the NHS!

The Patient Protection and Affordable Care Act decides who gets life-saving treatment and who does not. As over here, doctors will be advising elderly patients and counselling them to see the glass half empty and not the glass half full; to downsize their options and not expect expensive curative treatments. “Hello, EoLC…!”

Don Berwick, the said Director and administrator of Medicare and Medicaid Services, was responsible for a policy to pay doctors who advise patients on end-of-life care, and advance directives. This had been dropped from the Healthcare Reform Bill, should there be claims that it would encourage euthanasia.

This is changing. Ten health systems across the country have joined the Conversation Project since it launched in August 2012, pledging to be “conversation-ready” for patients and families by implementing systems to help prompt the talks and document expressed preferences.

Medicare doctors will make yearly medical “wellness” visits. Medicare will compensate doctors for discussing “voluntary advance care planning” and EoLC.

Effectively, they’ll be looking for their ‘one percent’.

The EoLC inquisition US-style -

Questions to start end-of-life care conversations

It can be difficult for patients of any age to talk about end-of-life care scenarios, whether with their doctors or loved ones. An initiative co-sponsored by the Institute for Healthcare Improvement provides questions that can get the discussion going.
  • When you think about the last phase of your life, what's most important to you? How would you like this last phase to be?
  • Do you have any particular concerns about your health? About the last phase of your life?
  • Who do you want — or not want — to be involved in your care? Who would you like to make decisions on your behalf if you're not able to? (This person is your health care proxy.)
  • Would you prefer to be actively involved in decisions about your care? Or would you rather have your doctors do what they think is best?
  • Are there any disagreements or family tensions that you're concerned about?
  • Are there circumstances that you would consider worse than death? (For example: long-term need of a breathing machine or feeding tube, or not being able to recognize your loved ones.)
  • Are there important milestones you'd like to meet if possible? (For example: the birth of your grandchild or your 80th birthday.)
Source: “Your Conversation Starter Kit,” The Conversation Project (link)

The EoLC inquisition UK-style -

End of life care: What to discuss

  1. 52. Patients whose death from their current condition is a foreseeable possibility are likely to want the opportunity (whether they are in a community or hospital setting) to decide what arrangements should be made to manage the final stages of their illness. This could include having access to palliative care, and attending to any personal and other matters that they consider important towards the end of their life.vii
  2. 53. If a patient in your care has a condition that will impair their capacity as it progresses, or is otherwise facing a situation in which loss or impairment of capacity is a foreseeable possibility, you should encourage them to think about what they might want for themselves should this happen, and to discuss their wishes and concerns with you and the healthcare team. Your discussions should cover:
  1. (a) the patient’s wishes, preferences or fears in relation to their future treatment and care
  2. (b) the feelings, beliefs or values that may be influencing the patient’s preferences and decisions
  3. (c) the family members, others close to the patient or any legal proxies that the patient would like to be involved in decisions about their care
  4. (d) interventions which may be considered or undertaken in an emergency, such as cardiopulmonary resuscitation (CPR), when it may be helpful to make decisions in advance
  5. (e) the patient’s preferred place of care (and how this may affect the treatment options available)
  6. (f) the patient’s needs for religious, spiritual or other personal support.
  1. 54. Depending on the patient’s circumstances, it may also be appropriate to create opportunities for them to talk about what they want to happen after they die. Some patients will want to discuss their wishes in relation to the handling of their body, and their beliefs or values about organ or tissue donation.
  2. 55. You must approach all such discussions sensitively. If you are unsure how best to do this or how to respond to any non-clinical issues raised by the patient, you should refer to relevant guidelines on good practice in advance care planning.viii  If the patient agrees, you should involve in the discussions other members of the healthcare team, people who are close to the patient, or an independent advocate.

In my humble experience, people aren't 'afraid' to talk about death - it's something that's going to happen to us all sooner or later - but death isn't exactly the high point of life, though it might be the culminating point.

Such a point would be the heroic death in a brave attempt to save another's life; the self-sacrificial death of the martyr, such as Jan Palach who immolated himself in Wenceslas Square before the Russian tanks. I use the word in its proper context here; those who make themselves into human bombs to make havoc, mayhem and death are not martyrs.

So, what are these LCP Red Brigadiers talking about? Dying matters, let's talk about it...?

And these are some pretty odd questions to bring up in talking about dying...

"Are there important milestones you'd like to meet if possible (For example: the birth of your grandchild or your 80th birthday.)?"

Hello - well, yes, you'd think so, wouldn't you? I'd like to; it just depends on how the cards are dealt (he shrugs nonchalantly).

Unless some croupier has stacked the deck by preventing access to curative care...? What they're really talking about is downsizing expectations, and giving you a helpful shunt into the next world. And getting you to agree to it.

This is grooming.

Don Berwick has stated clearly and categorically that it is not a matter of whether healthcare is going to be rationed but that it will have to be rationed "eyes open" via his and cohort Zak's Communitarian health policies.

This rule will lead, inexorably, to bureaucrats drafting guidelines as to who is “fit” to live and who is not. That isn't so alarmist as it sounds when you consider that Peter Singer was appointed the Ira W. DeCamp Professor of Bioethics at Princeton University. That's the same Peter Singer who does not view newborns as people or of having personhood and, in Psychology Today, advocated medical experimentation on humans in an unconscious and 'vegetative' state in hospitals.

There were “death panels” in Nazi Germany. In 'Beyond Obamacare', published September last year, Steve Rattner supports Death Panels.

Well, maybe not death panels but, sort of...

This is The New York Times -
"WE need death panels.
Well, maybe not death panels, exactly, but unless we start allocating health care resources more prudently — rationing, by its proper name — the exploding cost of Medicare will swamp the federal budget...
No one wants to lose an ageing parent. And with price out of the equation, it’s natural for patients and their families to try every treatment, regardless of expense or efficacy. But that imposes an enormous societal cost that few other nations have been willing to bear. Many countries whose health care systems are regularly extolled — including Canada, Australia and New Zealand — have systems for rationing care."
[Beyond Obamacare By Steven Rattner (A top Democrat strategist and donor who served as President Obama’s lead auto-industry adviser and as a counselor to the Treasury secretary in the Obama administration.]
Hello - "No one wants to lose an ageing parent" but... And this is where the Communitarians start talking about "fair" access to healthcare. Those most needy, the old, the frail and the fragile, the disabled are exactly those whose claims on the system are inordinate to their number.

The 'enormous societal cost' is something that simply cannot be borne so, come on now, the State expects everyone to do their duty - and die.

Interesting footnote: Ellershaw cites Berwick in his paper on the LCP here.

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