Here follows an extract from an evaluation report of implementation
of the GSF and LCP for people with dementia -
Care setting staff and stakeholder views and experiences
There is an emerging picture of overall staff confidence in the planning and implementation of end of life care for persons with advanced dementia. There is general agreement that the support of the GP and communication with the MDT is essential to the quality of end of life care within the care settings. Meeting the needs of the family carers could sometimes be challenging for care staff and the importance of a trusting relationship cannot be underestimated. Conflict between staff, colleagues and families was more apparent prior to or in the early implementation of the end of life care tools. Staff reported that this was often as a result of misunderstandings, communication difficulties with their colleagues or the family carer’s attitude and personal experiences of death and dying.
Economic Assessment and Appraisal
As a result of the End of Life Project and the care interventions, the aggregate percentage for dementia patients dying in a care setting increased from 48% (23 out of 48 deaths) to 63% (20 out of 32 deaths) for the two periods i.e. before and after, in the five project settings. This data represented the full financial year before the project started (viz. 2005/06) and the most recent full year of the project, when the initial training phase was completed, i.e. October 2006 – September 2007. The Control comparison group of homes all had high percentages for both periods. Ten residents/patients were transferred to hospital between October 2006 – September 2007. The average hospital length of stay before death for those transferred was 14 days. This could indicate a potential cost benefits to secondary care providers if acute hospital admission was avoided for people with dementia who need end of life care.
Often as a result of admission to a care home or hospitalisation dementia can sometimes advance extremely fast.
Prognostic indicators of 6-month mortality in elderly people with advanced dementia: A systematic review
As a result of the End of Life Project and the care interventions, the aggregate percentage for dementia patients dying in a care setting increased from 48% (23 out of 48 deaths) to 63% (20 out of 32 deaths) for the two periods i.e. before and after, in the five project settings. This data represented the full financial year before the project started (viz. 2005/06) and the most recent full year of the project, when the initial training phase was completed, i.e. October 2006 – September 2007. The Control comparison group of homes all had high percentages for both periods. Ten residents/patients were transferred to hospital between October 2006 – September 2007. The average hospital length of stay before death for those transferred was 14 days. This could indicate a potential cost benefits to secondary care providers if acute hospital admission was avoided for people with dementia who need end of life care.
The study demonstrates:
- That successful grooming is essential to successful implementation.
- That there are definite cost benefits to be obtained from implementation.
The study cites Kitwood (1997) that:
Often as a result of admission to a care home or hospitalisation dementia can sometimes advance extremely fast.
the Alzheimer’s
Society -
Eighty per cent of people living in care homes – more than ever thought before - have either dementia or severe memory problems
Dave Cameron has put a CQUIN bounty on dementia. The bounty hunters are out in force to hunt them down.
18 April 2013 Rebecca Todd
Royal Cornwall Hospitals NHS Trust is using software developed with IMS Maxims to help meet its Commissioning for Quality and Innovation targets for dementia care.
The Maxims dementia system prompts healthcare professionals to make relevant assessments for people with suspected dementia, while guiding them to the correct care pathway.
It also makes sure that the trust can claim CQUIN payments for delivering better dementia care.
Royal Cornwall’s associate director of nursing and consultant nurse for older people, Frazer Underwood, said the system meant the trust could identify all 75-year olds and make sure that they were assessed for dementia and referred as appropriate.
“It enables us to increase the early identification of people with dementia,” he added.
“In Cornwall, we have 10% more older people than the national average and the prevalence of dementia correlates with that higher figure. The ability of IMS Maxims to contribute meaningfully to improving services is invaluable.”
Shane Tickell, chief executive of the company, said: “The drive and innovation of Royal Cornwall Hospitals NHS Trust in using this system to manage the identification and referral process for dementia patients has produced excellent results.
“Working within the CQUIN framework has allowed us to develop software, which helps trusts become more efficient in administrative terms, while improving patient well-being and care.”
The IMS Maxims dementia software has been developed based on NICE guidelines.
However, this recent study published in Sage Journals throws doubt on the efficacy of such tools -
- Anna M Barron, Department of Biophysics and Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro-ku, Tokyo 153-8902, Japan. Email: barron.anna@graduate.uwa.edu.au
Abstract
Background: For end-of-life dementia patients, palliative care offers a better quality of life than continued aggressive or burdensome medical interventions. To provide the best care options to dementia sufferers, validated, reliable, sensitive, and accurate prognostic tools to identify end-of-life dementia stages are necessary.
Aim: To identify accurate prognosticators of mortality in elderly advanced dementia patients consistently reported in the literature.
Design: Systematic literature review.
Data sources: PubMed, Embase, and PsycINFO databases were searched up to September 2012. Reference lists of included studies were also searched. Inclusion criteria were studies measuring factors specifically related to 6-month outcome in patients diagnosed with dementia in any residential or health-care setting.
Results: Seven studies met the inclusion criteria, five of which were set in the United States and two in Israel. Methodology and prognostic outcomes varied greatly between the studies. All but one study found that Functional Assessment Staging phase 7c, currently widely used to assess hospice admission eligibility in the United States, was not a reliable predictor of 6-month mortality. The most common prognostic variables identified related to nutrition/nourishment, or eating habits, followed by increased risk on dementia severity scales and comorbidities.
Conclusions: Although the majority of studies agreed that the Functional Assessment Staging 7c criterion was not a reliable predictor of 6-month mortality, we found a lack of prognosticator concordance across the literature. Further studies are essential to identify reliable, sensitive, and specific prognosticators, which can be applied to the clinical setting and allow increased availability of palliative care to dementia patients.
No matter...
Alistair Burns is appointed Dementia Tsar forEngland
Alistair Burns is appointed Dementia Tsar for
The CQUIN aims to increase awareness around dementia as people are admitted to hospital. A flowchart has been developed for healthcare staff to use.
This inevitable flowchart is produced for the blind to lead the blind and has much in common with the LCP flowchart.
The inevitable acronym is produced to give it a snappy appeal: FAR.
This, then, is the FAR (Find, Assess, Refer) Dementia Care Pathway flowchart -
A cogent comment has been left on the DoH page in response:
Good point. There is a simple answer to this question.
Dave Cameron's dementia CQUIN has hit the nail home.
The slippery slope is becoming a rush toward the sheer drop.
And with the bonus ball of the 1%, they'll be really going for gold.
Diagnosing dementia means downsizing care expectations, to see the glass already half-empty. It is all about accepting palliative rather than curative care options.
The successful coding of the Dementia CQUIN will also extend downsizing to other aspects of care and facilitate implemention of the GSF and the LCP.
Remember, successful implementation is all about:
- Successful grooming as an essential precurser to implementation.
- The definite cost benefits to be obtained from implementation.
And dementia forms part of the GSF Prognostic Indicator Guidance.
Monday, July 25, 2011
I receive a call from Denise, a carer at The Meadows, the home where Mum has been looked after for the past year. I can tell from her tone that something is seriously wrong.
She tells me that Mum, who while showing early signs of dementia had been in relatively good health, has had a stroke and been taken to Addenbrooke’s Hospital.
Tuesday, July 26
Visiting hours are only 3pm to 5pm, and 7pm to 8pm. Mum looks so ill. She is awake. I talk to her and hold her hand. I say it is Carole and I’m sure she replies: ‘What now?’
I just want to comfort her. I know she will be feeling frightened as she hated being in different places, especially alone. An occupational therapist asks us all about Mum’s mobility status, whether she could walk using a frame. We say she was quite limited, and had been deteriorating over the past few months.
The doctor, a senior registrar in his last year of training, then says he can see us, and we are led to the ‘quiet room’. He explains that Mum has suffered a massive right-side stoke, and that given her dementia and very limited mobility, the best treatment would be palliative care. There was nothing that could be done for her.
They will not be giving intravenous fluids in case they lead to a chest infection, and there will be no quality of life for Mum [if she carries on].
Not nice to hear at all, yet I do realise that Mum is very ill. The doctor says that without fluids, the end will come within three to four days at the most.
When I come away from talking to him I am in a state of shock. I know Mum’s had a big stroke, but they are pretty much writing her off. When I come out of that meeting, I don’t expect her to last the week.
A female junior doctor speaks to us, informing us that there had been a discussion the day before and it had been decided to commence the Liverpool Care Pathway (LCP) for Mum. I have not heard of the LCP, so the doctor explains it is a plan of care put in place for the dying. Why weren’t the family told of this, or included in the discussion?
The fact that Mum had dementia and limited mobility has been mentioned a few times, and now it is mentioned again. Was this the criteria used to decide that all active treatment should be withdrawn?
On the second day, the doctor had said Mum would have no quality of life, but who really has the right to decide that?
A consultant comes later that day to sign the paperwork the junior doctor had commenced. It states that intravenous fluids had stopped on Wednesday night. He briefly explains what we had already been told: [there is] no active treatment, and most people cannot go longer than about three to four days without fluids.
It sounds so barbaric. That afternoon, we are moved to the side ward. Now Mum is there, does this mean she will soon die?
Tuesday, August 2
Another doctor comes with the scans and explains what happened when Mum was admitted. The scans show evidence of a massive stroke and how Mum’s brain had been previously damaged by dementia.
Although this provides some proof of Mum’s condition, I still feel very sad about it all, and uneasy that it means she is not being treated with any fluids, because it is perceived she would have no quality of life.
I say that Mum had been without fluids since Wednesday night. The doctor had not realised this, and could not understand how Mum could go so long without fluids.
I sit with her most of Tuesday night. She moans and taps her right knee. I notice that she has a large bruise around her knee, which I assume was the cause of her moaning and discomfort.
Wednesday, August 3
This is heartbreaking. How can anyone be so sure that there is no hope for anyone?
I explain to the registrar about Mum’s knee, how she had showed me this by tapping her leg. The registrar reviews her prescription chart and increases the diamorphine as he thinks Mum is in pain. I explain that I do not think she is in pain, but trying to communicate to be moved.
The registrar still advises the increase in diamorphine to be the best option. I guess Mum is just not doing what is expected, and that the lack of fluid is not working in the time expected.
One member of staff even says that ‘it was hot, therefore (my mother) would lose more fluids so it would not be much longer’. I also understood that I should not even put a damp cloth to my mother’s mouth in case she gleans some moisture from it, which would prolong her life.
Surely health professionals must realise they are looking after human beings with feelings, not just ‘objects’ to be dealt with in a textbook fashion?
COMMENTARY -
The fact that Mum had dementia and limited mobility has been mentioned a few times, and now it is mentioned again. Was this the criteria used to decide that all active treatment should be withdrawn?
POST-stroke Dementia
The GSF Prognostic Indicator GuidanceThe National GSF Centre’s guidance for clinicians to support earlier recognition of patients nearing the end of life
Step 3
Specific Clinical Indicators - flexible criteria with some overlaps, especially with Those with frailty and other co-morbidities.
c) Frailty / Dementia – gradual decline
Cognitive impairment / Post-stroke dementia.
The doctor says that without fluids, the end will come within three to four days at most.
Thus, withdrawing fluids will hasten death/is intended to hasten death.
A female junior doctor speaks to us, informing us that there had been a discussion the day before and it had been decided to commence the Liverpool Care Pathway (LCP) for Mum. I have not heard of the LCP, so the doctor explains it is a plan of care put in place for the dying.
On the second day, the doctor had said Mum would have no quality of life...
The LCP ‘is a plan of care put in place for the dying….’
Is the person dying or are they not dying? So-called 'quality of life' is not a criteria that enters into the equation.
A consultant comes later that day to sign the paperwork the junior doctor had commenced. It states that intravenous fluids had stopped on Wednesday night. He briefly explains what we had already been told: [there is] no active treatment, and most people cannot go longer than about three to four days without fluids.
The consultant thus confirms that withdrawing fluids will hasten death/is intended to hasten death. That is euthanasia; That is unlawful.To give this unlawful act a cover of 'legality' the LCP 'paperwork' is signed.
I say that Mum had been without fluids since Wednesday night. The doctor had not realised this, and could not understand how Mum could go so long without fluids.
The doctor confirms once more that the withdrawing of fluids will hasten death/is intended to hasten death.
The registrar reviews her prescription chart and increases the diamorphine as he thinks Mum is in pain. I explain that I do not think she is in pain, but trying to communicate to be moved.
 |
| The Rise of Stealth Euthanasia - Imposed Death Disguised as Pain Relief |
The registrar still advises the increase in diamorphine to be the best option. I guess Mum is just not doing what is expected, and that the lack of fluid is not working in the time expected.
One member of staff even says that ‘it was hot, therefore (my mother) would lose more fluids so it would not be much longer’. I also understood that I should not even put a damp cloth to my mother’s mouth in case she gleans some moisture from it, which would prolong her life.
Intentionality is being called, more and more, into question. The Pathway is a pathway with a design, a direction and a final destination.
Dave Cameron's dementia CQUIN has hit the nail in the coffin.
- The Telegraph
Dr. Michael Irwin who appears to celebrate in
the notoriety of the pseudonym of ‘Dr. Death’ (The British Nitschke) has aided an elderly British man
diagnosed with dementia to go to Switzerland
The success of Dave Cameron’s CQUIN will mean
more and earlier ‘diagnoses’ of dementia.
Will we see, also, a rush of lemmings to meet their maker...?
This a frightening thought. Will people feel pressured, be pressured to act...?
 |
| - Mail Online |
The Communitarian Complete Lives trajectory means that the over 65s are on the lower end of the scale of priority for receiving treatment.
Curious, therefore, that research now shows that over 65s are ill-advised, it seems, to accept treatment that involves a surgery that entails a general anaesthetic...
That'll make the grooming a whole lot easier.
I thought a screening test should only be put in place if it could do more good than harm i.e that there was a good treatment that one could offer.
I don’t think there is a cure for alzheimers, and in fact many meds on offer for it seem to cause as much harm as good.
Thus, when the NHS is seeking to use it’s limited budget to maximum benefit, how can the DOH be spending on promoting this screening.
Often people become very anxious at the suggestion that they have a degree of dementia, and fear loosing their independance.