Sunday, 30 June 2013

Liverpool Care Pathway - This Disgraceful Arrogance

Some doctors are cursed with arrogance; others are blessed with humility. Though one claimed by some, infallibility is not a recognised human trait.

Pulse reports on the Annual Representatives Meeting of the BMA.

This is the infamous motion to back the LCP -

Motion in full

Motion to be proposed by the Harrogate Division:

That this Meeting:
i. notes that recent adverse media coverage has caused some patients and relatives to lose confidence in the Liverpool Care Pathway (LCP);
ii. affirms the value of the Liverpool Care Pathway in delivering excellent end of life care for dying patients;
iii. believes that strategies to implement the LCP must reward quality of care and not the frequency of use;
iv. supports the appropriate use of the Liverpool Care Pathway and palliative care in the UK;
v. asks the BMA to request that teaching in using end of life care pathway to be part of medical school curriculum. 

Even Baroness Ilora Finlay of Llandaff, professor of palliative care medicine at Cardiff University, advised caution. There is, after all, a government review under way. Still, the doctors were persuaded by propaganda and spoof to plunge in to provide their support.

Strategic positioning

This was rather reminiscent of the manner in which the BMA's stance on euthanasia was modified in 2005. By connivance and artifice, that was achieved. That change of stance has enabled all manner of nasties to advance their cause and has pulled the rug from under the feet of those who oppose it. Where was the mandate?

So, do delegates/representatives at the ARM have access to the deliberations of the Review panel that the rest of us - and, mayhap, certain members of the panel! - do not? Or do they hope to pre-empt and, thereby, influence the outcome of those deliberations  by throwing down the gauntlet to its members that they do battle with such an august body as the BMA itself and that is no trifling matter?

The ARM of the BMA is akin to the AGM of any Trade Union in the land. The bulk of it is politics.

Politicians are a notoriously treacherous and untrustworthy breed. Politicised doctors add a whole new dimension to that perspective in an arrogant belief in self-righteous infallibility.

It is an unfortunate characteristic, that is not universal, but is often particular, that these persons do possess a ‘god complex’.

Any profession, the medical profession included, should have as its focus professional matters, the ethics and practice of their profession, and yet, politicians being politicians, this will, and does, overlap into all manner of unrelated areas.

It appears to be a complex amongst certain of these professional people in their rantings abroad the net in support of the LCP and rubbishing its opponents to declare themselves ‘atheist’ - which does seem rather odd of people possessing the most definite traits of the 'god complex'.

What has their personal stance on the existence or non-existence of a divine being to do with the documented facts of a failed and ethically questionable protocol much publicised as such - and rightly so - in the press? It is almost a statement of denial of ethics...

These doctors, when confronted with an argument they cannot immediately answer, will often respond by going on a skew, asking what is the religious standpoint of their antagonist. It is as if the mere fact of professing or possessing such a viewpoint or belief is grounds and just cause sufficient to dismiss the argument.

Such sanctimonious bigotry from those denying any allegiance to a god-head seems, at once, inapposite and yet fitting - when one considers that these persons may possess the 'god complex'!

Such persons do great discredit and disrespect to fellow supporters of the LCP such as Dr. Peter Saunders, CEO of Christian Medical Fellowship.

Dr. Saunders expounds support for the LCP and publicises the matter of his religious affiliation in the same manner that these other doctors expound their a-religious or non-religious affiliation. He does not bring that into his argument in debate on the LCP, however. But then, perhaps, Dr. Saunders does not have a 'god complex'!

Dr. Saunders is a paradigm of the politicised doctor with telescope vision, however.

Thus, even though invited in debate and discussion as CEO of Christian Medical Fellowship on a programme called Everyday Ethics , he could not grasp that significance and purpose of his invite and that of his co-debater, Professor Patrick Pullicino, consultant neurologist at East Kent Hospitals and Professor of Clinical Neurosciences at the University of Kent.

It would seem that some doctors are cursed with arrogance, whilst others are blessed with humility. It would seem that some doctors profess religious or spiritual leanings because of what they are - others, because of WHO they are.

It is noteworthy that politics intrudes to suppress as well as to promote. What happened to this draft proposal? Can anyone enlighten me or advise...?

Draft motion to the BMA Annual Representative Meeting
We would be grateful if BMA members could consider submitting the following ARM motion via their branch or committee…

‘This conference:

1) Notes BMA motions in 2007 and 2012 that acknowledged the close links between the medical profession and the pharmaceutical industry and stated that these interactions can adversely influence prescribing.

2) Notes that the BMA is signatory to a document produced by the Ethical Standards in Health and Life Sciences Group called Guidance on collaboration between healthcare professionals and the pharmaceutical industry (2012) alongside the Association of the British Pharmaceutical Industry and various medical bodies.

3) Applauds the document’s aim of ‘ethics’ and ‘transparency’ but believes it is flawed for the following reasons

a) The document states that ‘medical representatives’ can be a ‘useful source of information for healthcare professionals’ and that ‘Industry has a valid and important role in the provision of medical education’.

b) The document does not acknowledge the best currently available evidence, a systematic review (Spurling et al, 2010), which shows that doctors who are exposed to information from pharmaceutical companies, such as pharmaceutical sales representative visits and attendance at pharmaceutical sponsored educational meetings, tend to prescribe more frequently, less appropriately and at higher cost than other doctors.

c) The document implies that all industry-sponsored trial data is publicly available, when this is untrue (Goldacre et al, 2013) and access to withheld information about clinical trials is the subject of a prominent on-going campaign, questions in Parliament, and at least one parliamentary select committee enquiry.

4) This conference believes

a) That the BMA should publically withdraw its support for the document

b) That the BMA should advocate for the other signatories to do the same

Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, et al. (2010) Information from Pharmaceutical Companies and the Quality, Quantity, and Cost of Physicians’ Prescribing: A Systematic Review. PLoS Med 7(10): e1000352.

Goldacre B, Heneghan C, Godlee F, Chalmers I (2013). Missing trials briefing note. Available from (accessed 16 January 2013).

Friday, 28 June 2013

Liverpool Care Pathway - An Analysis With An End In Sight

When analysis is determined by foresight instead of hindsight, scientific objectivity always takes a back seat to wishful thinking!

This is The Journal of the Royal College of Physicians 

This is the abstract:

This paper describes three elderly patients who were admitted to hospital with aspiration pneumonia. They were kept nil by mouth (NBM) for a number of days, while being given intravenous hydration initially and enteral feeding subsequently. During that time they deteriorated and appeared to be dying, so the Liverpool Care Pathway (LCP) for the dying was used to support their care. Artificial nutrition and hydration were stopped. They quickly improved and the LCP was discontinued. Two of the patients deteriorated again on reintroduction of enteral feeding and/or intravenous fluids, only to improve a second time following withdrawal of feeding and fluids. Vulnerable elderly patients should not be made NBM except as a last resort. Clinicians should be alert to the possibility of refeeding syndrome and overhydration as reversible causes of clinical deterioration, particularly in frail elderly patients. Use of the LCP in these patients provided a unique opportunity to witness the positive effects of withdrawal of excessive artificial nutrition and hydration.

Upon initial observation of the document:

In regard to the unanticipated clinical improvement, as the authors do themselves correctly summarise in this abstract, these positive effects were a result of withdrawal of excessive feeding and hydration - not of application of the LCP.

Upon scrutiny of the document:

Without benefit of access to the complete paper I can only draw conjecture on the basis of the abstract. However, it would appear from summary review of the abstract that a fundamental error of deduction has occurred.
This is likely through prejudicial assumption that an action of applying an entire protocol – the LCP - has produced an outcome that is, in fact, both a consequence and bi-product of application of one process of that protocol – fasting! ['withdrawal of excessive feeding and hydration']
Releasing the body from one function – digestion - can permit limited bodily resources to provide focus on another – healing. The title of the paper draws attention to this: “Overfeeding and overhydration”!
It is a nonsense to say that this is a 'lesson' from the LCP, therefore. It is but a chance beneficial observation, akin more to the discovery of penicillin. 
Sir Alexander Fleming's revolutionary discovery was made by the chance contamination of an experiment. That discovery was no more a 'lesson' to be drawn from contaminating experiments than is this discovery a 'lesson' from applying the LCP!
Without benefit of access to the complete paper, of course, I can only draw conjecture on the basis of this abstract.
However, in the actual ward setting, on the LCP, the drivers are always at the ready and improvement is often masked by application of the protocol.
Furthermore, it is likely that reviews in the ward setting are not as thorough as those applied by the paper’s authors and certainly not up to the standards that Dr. Howard has described as should be undertaken.
As Dr. Howard  points out, according to the audit  that was done of 7000 patients two years ago, only 20% were reassessed.
Therefore, in the real world these three patients, likely would have continued on the regimen and starved to death.
In the real world, in the actual ward setting, these three patients would likely have been placed on the LCP at the outset!

The Liverpool Care Pathway for the Dying Patient is precisely that. Unfortunately, it is more than that...

It is the Liverpool Care Pathway for the Patient Diagnosed as Dying!
It is not a curative protocol; it is a palliative protocol!
The Twitters tweeting in abundance are demonstrating only their profound ignorance and unforgivable arrogance!
Fasting as a restorative protocol has been well known for centuries, both for its spiritual and physical benefits. These days, popular culture would, perhaps, refer to this practice as 'going on a detox'!
This, if there is one, is the 'discovery', the 'lesson' to draw.


Corrupting experiments is no more a recommendation to make grand discoveries than is applying the LCP!!!!

Further reading -

Liverpool Care Pathway - The Dangers Of Arrogance And The Arrogance Of the Arrogant

Thursday, 27 June 2013

Liverpool Care Pathway - BMA All The Way...?

The BMA is quite unanimous... Again! Apparently. But back in the real world, we're all a tad underwhelmed by it all.

Everyday Ethics hosted a debate between Dr.Peter Saunders, CEO Christian Medical Fellowship, and Professor Patrick Pullicino, consultant neurologist at East Kent Hospitals and Professor of Clinical Neurosciences at the University of Kent.
William Crawley, the Everyday Ethics host, very cleverly and very skilfully drew on the Christian ethics of both men to question the ethics of the Liverpool Care Pathway.

Sadly, Dr.Peter Saunders deemed it necessary to misrepresent the facts of the BMJ survey for Dispatches; and so forthrightly did he speak and with such authority that no-one dared to question him:

"Ninety-eight percent  of over 3000 doctors who were surveyed for the British medical journal in the last week...Ninety-eight percent said that, if appropriately used, it can help people to die much more comfortably."
This BMJ article asked -
The Liverpool care pathway: what do specialists think?
It must be said, a marvellous array of graphs were provided to give, well... a graphical illustration of the results.

The feature mentioned that, of 3021 UK hospital doctors emailed for an anonymous online survey of their views on the Liverpool Care Pathway, only 647 responded. That's only 21.4% of the 'over 3000' doctors.

Only 90% of this 21.4% responded favourably. That being the case, that nine out of ten 90% doesn't look nearly so good... And it's certainly not 98% of the 3021!

Who are these 3021 doctors, in any case? Why were they singled out for the survey? There are, apparently, some 231,000 doctors on the Medical Register as at 2010.

Are they unemployed standins from the Young Doctors set...?

Speaking of young doctors...

Back in April, the young doctors had their own little get together at the Medical Students Committee Conference at the BMA.

Yes, at the BMA again.

And they were all happily tweeting away as twits tweeters do -
@Quinnfeld "Motion 101: To issue a robust statement of support for the Liverpool Care Pathway. #LCP #StudentsLive "
@CrashCall "Unanimous vote in favour of statement strongly in favour of the LCP, in light of erroneous and damaging press stories. #StudentsLive "
@PeterDMurray "Very pleased @BMAstudents unanimously endorsed the Liverpool Care Pathway & rejected lies propagated by tabloid media outlets #studentslive "
@RoseTintdScrubs "@mailonline 's disgraceful attacks on #LCP condemned in first unanimously passed motion. #studentslive "
Is this, truly, the next generation of doctors…?

Good Sirs, good Ladies, you bring yourselves into disrepute, if not the BMA. You insult the victims and loved ones who have suffered at the hands of your colleagues and your wretched, damnable Pathway!

Even arch LCP apologist, Norman Lamb, could not keep the lid on it and had to call the 'Review' to apply a coat of whitewash!

And, once again, following the example of their juniors, the BMA doctors 'overwhelmingly' back the LCP -


However, Yorkshire GP, Mark Pickering, admitted that ‘the LCP may not be perfect.’

Leicester medical student, Sasha Marie, called for training.

BMA president elect, Baroness Finlay, said that media coverage had been damaging...

And called for nurses as well as doctors, to get LCP training.

Hello! Does she mean to say that the doctors and nurses practicing the LCP are not trained, or are not adequately trained? That is damning if true!

Hang on. What about all the training rolled out by Dr. Bee Wee? Was all that not worth a jot? Or were they trained in EoLC by reading that Nursing Times article? Readers of these pages will know to what I refer!

The Baroness said that families had become terrified. Can you blame us?

Chairman Ellershaw admits that Dr. Pullicino is perfectly correct in his assertion that diagnosing dying is not scientifically possible and Baroness Finlay confirms that it is questionable to predict prognosis in the last hours of life and that "basically, we are often wrong".

Tony Calland then put his size nines in it and said that it's important to demonstrate that doctors "Actually know what they are talking about" when it comes to the TLC in the EoLC!

Well, that takes the biscuit. 

Wednesday, 26 June 2013

Liverpool Care Pathway - The New Spectator Sport

The Roman Games kept the rebellious masses in awe of their masters. They had a political purpose.
What purpose does this serve?

Is this the descent of culture? 

Have the Ghouls sucked out our souls that this is now our entertainment?

Are these the sort who used to rush to watch the entertainment  at the public hangings at Tyburn or the guillotine at the Bastille?

Is this the new grim spectator sport, the spectacle of watching someone die?

The raison d’être of Johnnie Cash’s anti-hero to kill a man in Phoenix just to watch him die...

This is LifeSite News 

And the final word -
The Dutch Association for Voluntary End of Life said the documentary would become a teaching tool. 
“Young people need to become more conscious of the possibility of euthanasia,” they said.

Liverpool Care Pathway - The Shame Of The Shameless

How can this man show his face in public and feel no shame?
When he looks at the man in the mirror, does he feel no shame?

Is he for real…?

This is Mail Online 

There have been cover ups...

and cover ups of cover ups of cover ups!

Hang down your head, Dave Nicholson...
       Hang down your head, Dave Nicholson
       Hang down your head, don't lie
       Hang down your head, Dave Nicholson
       Boss man, you just stood by

       While they killed them on the ward round
       They left them there to die
       They never heard them screaming
       They didn't hear them cry

       You can plead ignorance
       You can say you didn't know
       Hadn't been for Julie Bailey
       None of us would know

       Own up, now, Dave Nicholson
       Or reckon where you'll be
       Makin' your defence
       Before an Inquiry

       They'll strip you of your knighthood
       Shamed by infamy
       The noble hand that gave it
       Dave, get down on your knee

       Hang down your head, Dave Nicholson
       Hang down your head, don't lie
       Hang down your head, Dave Nicholson
       Boss man, you just stood by

      Hang down your head, Dave Nicholson
      Hang down your head, don't lie
      Hang down your head, Dave Nicholson
      Boss man, you just stood by

      Hang down your head, Dave Nicholson
      Hang down your head, don't lie
      Hang down your head, Dave Nicholson
      Boss man, you just stood by

        [With apologies to the Kiingston Trio]

Liverpool Care Pathway - For The Patient Who May Be Dying!

The LCP really is the LKP, a Licence to Kill People.
What else is it than that...?
It's the Euthanasia Bill that bypassed Parliament.

It's all so matter of fact. No-one's thinking straight. No-one's thinking...

And that's what they're counting on. It's all just slipped in under the radar.

More on twitter -

This is 
Cllr Ken Wyatt @kenwyatt (Councillor for Swinton & Kilnhurst; work in aspects of Criminal Justice Services; published author; film-maker & historian.)
Just heard that my elderly aunt maybe approaching the end of life; staying put in her curent home with Liverpool Care Pathway in place.

Well, that says it all, doesn't it? May be approaching the end of life...

Well, it is a CARE Pathway. Supposedly.

Perversely, no.

When caring is most required, it is withdrawn; when compassion is most wanted, it is found wanting.

Caring is an obligation upon the human condition. It is a privilege of service; it is a catharsis for the soul.

So the lady 'may be' approaching end of life. Well, that certainly will be the case with the LCP in place.


Spending some time with someone at the end of their life; she's comfortable, serene, aware of our love & with an appropriate pathway.

Liverpool Care Pathway - Going Stateside

Attention America, be on your guard...
They're hunting down your 1%.

It used to be just part of getting old. You slow down. You’re puffy going up the stairs, walking round the block. It doesn't mean you're checking out anytime soon. It's just the natural course of things.

Not anymore.
Doctors should screen all adults over age 70 for frailty, a medical syndrome that affects 5 percent to 10 percent of people in this age group, according to a new consensus statement from six international medical organizations.

Frail seniors are tired, weak, thin and listless, with a reduced ability to bounce back from physical challenges and a greater risk of becoming disabled, dependent and dying earlier than others of their age. This was first identified as a condition worthy of attention in the medical community in the 1990s by Dr. Linda Fried, now dean of the Columbia University Mailman School of Public Health.
This is Learning to Spot Frailty (Or, in other words, the US version of "Find Your 1%"... )

This is New York Times 

The Edmonton FRAIL Scale

"As frailty advances, it is appropriate to shift the focus of care to palliation"

Frailty as a syndrome

Fried et al defined frailty as a syndrome arising from the “physiologic triad” of sarcopenia and immune and neuroendocrine dysregulation. Patients are considered frail if they have three or more of the following five criteria:
  • Reduced activity
  • Slowing of mobility
  • Weight loss
  • Diminished handgrip strength
  • Exhaustion.
Someone who has only one or two of these items is said to be “pre-frail”; someone with none is said to be “robust.”
The FRAIL scale. The Geriatric Advisory Panel of the International Academy of Nutrition and Aging formulated a scale for measuring frailty as a “pre-disability state.” The FRAIL scale consists of five easily remembered items:
  • Fatigue
  • Resistance (inability to climb one flight of stairs)
  • Ambulation (inability to walk one block)
  • Illnesses (more than five)
  • Loss of weight (> 5%).

"Because of the rapid rate of growth in the population aged 65 years and older, the number of frail elderly persons is increasing every year"

Frailty: Are we able to identify the older adult who is frail? A discussion on methods and limitations’ 
Neil Pendleton - University of Manchester

A report in Mail Online says: Patients in their 50s are three times more likely to be offered emergency treatment for heart attacks than those in their 80s. 

This is not ageism; this is Communitarianism.

It was reported by the Mail Online on 13th March that our hospitals are dangerous and that the vulnerable and the elderly should not be treated there. No-one could reasonably disagree that hospitals have become very dangerous places. Isn't the sensible response to make our hospitals safe...?

This is all a tactical shift of emphasis. The frail and the fragile, the vulnerable and the elderly, are to be treated in the community for their own protection! What a clever ruse. What cunning... What a wheeze...!

Dave Cameron has installed Don Berwick as a guiding tsar to the NHS. 

What, that Don Berwick, running for governorship for Massachusetts, Medicare Director under the Obama administration, cohort of Ezekiel "Zeke" Emanuel, promoter of Communitarian Healthcare, delaying or denying access to medical innovations if your Communitarian profile doesn't fit? That Don Berwick.


This is not ageism. It is the Communitarian healthcare promoted by Zeke and Don.

And it's going Stateside.

Monday, 24 June 2013

Liverpool Care Pathway - They Say They Can Diagnose Dying

Life is resilient; life always strives to be.
Life is precious, and that is why living matters.

They say they can diagnose dying but they can’t always be certain they have diagnosed death.

They declared May to be dead, then found a faint pulse...

Mail Online
Three or four Britons come back from the dead each year, a leading medical conference will hear.

Official figures show that between 2009 and 2011, ten patients were declared dead too quickly.In one case, a family that had just been told their loved one had died walked into the room to find that she was breathing.

The woman, who has not been named, never regained consciousness and died eight hours later.

However, the premature declaration of her death caused her family ‘extreme distress’, the National Patient Safety Agency has said.

The health watchdog is aware of nine other cases – and that this is likely to be an underestimate.
The premature diagnosis of dying and consignment on the LCP to a premature death has caused families 'extreme distress' and utter devastation!

They say they can diagnose dying, they say they can diagnose dying, they say they can diagnose dying...

There is absolutely no scientific basis to that claim!

They have been diagnosing dying for years, so sure in their arrogance they have got it right, but the research still goes on. If the research still goes on, then they're still not sure. And they are now on their 12th version of the LCP. So they haven't been too sure about that, either. So, what wrongs and compounded wrongs have been done in their name...?
"Placing a patient on the Pathway is a decision with an end in view. The patient is dying. Why? Because we say they are dying. Why? Because we have decided." (Dr Philip Howard)
And here it is straight from the horses mouth: Chairman Ellershaw in his own write. On the University of Liverpool website, the Marie Curie Palliative Care Institute –

Recognising when patients are approaching the imminently dying phase (the
last hours or days of life) is an important aspect of providing end of life care,
for example enabling appropriate communication with family and considering
patient priorities such as any specific religious or cultural needs, or preferred
location for end of life care. However, this recognition can be challenging and
multiple factors need to be considered. Every patient, each with their own
individual characteristics, makes them, and the course of their illness,
unique. An editorial of the Journal of Palliative Medicine in August 2007
stated, “It might strike lay people as odd, but there is little empirical data on
the physician skill of diagnosing imminent death. It would appear that much
remains to be learned.” There is limited evidence in medical literature of how
the dying phase can be identified

Recognising the imminently dying phase is complex and a variety of factors
appearto be considered by experienced hospice staff in this study. While the
qualitative study & subsequent Delphi cannot provide all the answers to the
complex and multi-factorial process of recognising the dying phase, this
Delphi has helped gain further consensus on aspects of this process building
on the previous qualitative research. Outcomes of the Delphi could be used
as a basis for future research for quantitative study or for development of
educational tools

And just so you can be sure you know how to diagnose dying, a wordle has been created especially for that purpose...

Now, isn't that fun?