Monday, 24 June 2013

Liverpool Care Pathway - Self-Accreditation...?

They have made a diagnosis of dying.
They have prescribed the LCP.
What guidelines do they use?
What adjustments do they make?
What qualifies them so to do?

May's story is here:
A True Story
A True Story Supplemental
They put her on a driver on the LCP. When the deed was done and the end came some 18 hours later, a further syringe - a large, hefty one - was found on the bed where May had departed this world. It was thought to have been lying beneath her. Were the correct conversion guidelines followed?

How are Certificates of Learning Obtained?

Apparently... reading the Nursing Standard -

By reading this article and writing a practice profile, you can gain a certificate of learning. You have up to a year to send in your practice profile. Guidelines on how to write and submit a profile are featured at the end of this article.

Opioid conversion guidelines vary substantially. Which guidelines did they use? What did they put in May's driver?

Did they make the necessary adjustments? What qualified them to make those adjustments?

This is the American Pain Society (APS) 32nd Annual Scientific Meeting.

This is Medscape Today - 

Nine Guidelines
This research was conducted to address concerns associated with conversion estimates, including the overestimation of equianalgesic doses and failure to consider incomplete cross-tolerance, the likely pain trajectory, comorbid conditions, concomitant medications, and variability between patients.

The analysis was limited to 9 evidence-based, pain management guidelines that included equianalgesic conversion doses (4 national guidelines and 5 state guidelines). The authors found substantial variability across both national and state guidelines regarding morphine equivalent dose factors, generally in 3 areas: variable ratios, fixed ratios, and no equianalgesic dose given for methadone.

Six of the 9 guidelines recommended that a pain specialist be consulted when using methadone. California was the only state guideline to address the fact that conversion from methadone to morphine is not bidirectional, Erensen noted.

In the national guidelines, the greatest variability was observed for hydromorphone and oxycodone, whereas consistency was observed in state guidelines primary due to adherence to the Washington State Agency Medical Directors Group guidelines.
Numerous publications were identified for opioid conversion ratios across the guidelines. These studies have substantial variability related to type of publication, timeliness of the information, number of patients, and study design. Sources ranged from review articles to expert opinion, case studies, clinical studies, and studies that were withdrawn or superseded. Most were not well-controlled, multiple-dose trials in patients with chronic pain. Five of the studies were published in the 1990s in fewer than 30 patients.

Given these findings, the authors conclude, "it is imperative that practitioners are aware of these clinically meaningful limitations and consider the reliability and applicability of these conversion ratios to the setting of chronic opioid administration. Likewise, legislators and regulators contemplating the use of conversion ratios in implementing pain policies should understand the unresolved variability and lack of bi-directionality in conversion tables. Efforts to determine scientifically sound conversion recommendations should continue and, once determined, they should be widely available (eg, FPIs, websites)."

Providing some perspective on these findings, Samuel A. McLean, MD, MPH, an emergency physician at the University of North Carolina School of Medicine in Chapel Hill, said the study raised important concerns.

"For patients who require any dose adjustment, whether due to acute medical illness or opioid tolerance, it is critical to make the initial conversion correctly," he told Medscape Medical News. "It is concerning to see that physicians are making decisions based on data that are at times flawed. Incorrect conversions can result in tremendous patient suffering and raises concerns about worsening of disease or addiction."

Ms. Erensen is an employee of Purdue Pharmaceuticals LLC, the company that funded the study. Dr. McLean has disclosed no relevant financial relationships.

American Pain Society (APS) 32nd Annual Scientific Meeting. Abstract 193. Presented May 9, 2013.

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