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

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