Wednesday, 7 August 2013

Liverpool Care Pathway - Murder On The NHS Express

It's not the crisis, it's what you do with the crisis. It's not the moment, it's what you make of the moment.

Some doctors are cursed with arrogance, whilst others are blessed with humility.

Honesty is a virtue not unknown, but rare, among politicians. Politicians, like doctors, are not humbled nor restrained but enamoured by their arrogance.

Never let a crisis go to waste – Rahm Emanuel...

Rahm Emanuel on the Opportunities of Crisis

"You never want a serious crisis to go to waste. And what I mean by that is that it is an opportunity to do things that you think you could not do before. This is an opportunity what used to be long term problems, be they in the health care area, energy area, education area.... Things that we had postponed too long that were long term, are immediate and must be dealt with." - Rahm Emanuel

This is Zeke, Rahm's elder bro', reported in the New York Post -
Emanuel, however, believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those "who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia" (Hastings Center Report, Nov.-Dec. '96). He explicitly defends discrimination against older patients: "Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years" (Lancet, Jan. 31). The bills being rushed through Congress will be paid for largely by a $500 billion-plus cut in Medicare over 10 years. Knowing how unpopular the cuts will be, the president's budget director, Peter Orszag, urged Congress this week to delegate its own authority over Medicare to a new, presidentially-appointed bureaucracy that wouldn't be accountable to the public.
How do you do more with less? How do you spend money to save money?

Cutting costs means cutting care means downsizing care means downsizing care expectations. Patients groomed to expect less, make a 'living will' - sign an Advance Care Directive or Death Warrant - to that effect, agree to organ harvesting, cost less.

In other words, ensuring that palliative rather than curative options are pursued. The impossible is achieved by making it laudable and desirable.
Healthcare professionals are encouraged to 'keep them at home'.

Ambulance crew may well not remove to hospital a patient flagged up as being on an EoLC register. The June 2010 Macmillan End of Life Care Newsletter shares the National End of Life Care Programme logo and is published by NHS. From the Newsletter - "Discuss with family and friends how to get care and help at different times. Specifically advise that calling 999 is very seldom appropriate and may result in resuscitation, transfer and admission." Where are we going with this...?

This is from Liverpool Care Pathway - For The Downsized Patient -

According to Jane Barton and the Gold Standards Prognostic Indicator Guidance, one of the triggers that suggest patients are nearing the end of their life is the ‘surprise question’ which is, basically, an assessment of their general demean.

In other words, it is a matter of subjective judgement.
According to Jane Barton and the Gold Standards Prognostic Indicator Guidance, it is an intuitive assessment of clinical, co-morbidity, "body language" and "social and other factors that give a whole picture of deterioration".

It is an assessment of quality of life.

The Liverpool Care Pathway was developed by Royal Liverpool University Hospital and Liverpool's Marie Curie Hospice in the late 1990s for the care of terminally ill cancer patients.

At that time, the Liverpool Care Pathway was the Liverpool Care Pathway for the Dying Patient already diagnosed as dying.

Since then, the scope of the LCP has been extended to include all patients deemed dying. Patients are not being diagnosed with a potentially life-limiting  illness; they are actually being diagnosed as 'dying'. 

The Liverpool Care Pathway for the Dying Patient is no longer the Liverpool Care Pathway for the Dying Patient.

A spade is a spade

Why not call a spade a spade?

The LCP is a tool. It is a spade. It is a spade with which is dug the patient's grave.

It was, from its original conception, and is a cover for the practice of euthanasia long extant in British hospitals.

Consideration of 'futility' of treatment is a subjective observation.

It is an assessment of the 'quality of life' of the downsized patient.

In a climate of limited available resources, factored in with economic pressures that refuse to go away, however, there are more sinister forces at work.

Government sources continue to warn of the growing burden of elder care. Stark warnings and projections are made.

For instance:
The number of older adults is increasing • The absolute number of older adults and their proportion in the population is significantly increasing. From 1983–2008, the proportion of the total population aged 75 years and over in England increased by a third from 6% (2.9 million people) to 8% (4.0 million people). The population aged 75 and over is projected to increase to 7.2 million in 2033, and the number of people aged 90 and over is projected to increase from 0.4 million in 2008 to 1.2 million in 2033.(Office for National Statistics). • Increases in the ‘oldest’ population have resulted from falling mortality rates in the second half of the 20th Century and increased birth rates at the beginning of the 20th Century (Dini & Goldring, 2008). In the UK, from 1968–2008 mortality rates declined by 51% in males and 43% in females (Office for National Statistics, 2009). • In England, life expectancy (period expectation of life at birth) increased by over 6 years in males from 1980–82 to 2006–08, from 71.1 years to 77.7 years, and by over 4 years in females, from 77.0 years to 81.9 years (Office for National Statistics).National End of Life Care Intelligence Network
These factors sit very much at the heart of forward planning. The pensions black hole coupled with the cost of care of an elder population is causing nazti ideas to come crawling out of the woodwork.

Keeping people alive is a costly business

The euthanasia lobby has found growing support on both sides of the House and in both Houses. This isn't just about 'dignity in dying'; it is about digging the economy out of the pensions and benefits black hole into which it is plunging by filling it with the corpses of  the most frail and the most vulnerable members of the community.

Diagnosing dying and putting patients on a pathway sounds like death with dignity but it's going to save governments, and the taxpayers who fund them, a lot of dosh.

Of course it's not about killing people, but it's still cheaper to kill the seriously ill than to keep them alive in hospitals, nursing homes or hospices. This isn't just about pensions and benefits. Hospitals under financial pressures and bound by targets don’t want bed-blockers clogging the wards eating up finite resources.

Of course there's no dark government plot to murder old people, but deficit-burdened Governments have other considerations.  Death, particularly for the frail and the fragile elderly, the vulnerable and the disabled in mind or body, is a final and lasting solution.

Along comes a crisis. Never let a crisis go to waste – Rahm Emanuel.

A crisis is an opportunity to do things that you thought you could not do before. It is an opportunity for what used to be long term problems, things we had postponed too long that were long term and must be dealt with. The 90s were a testing ground in the Hospices to make comfort care a recognised medical protocol. The Barton crisis prompted the roll-out of that protocol across the NHS. What Amis has called the 'silver tsunami' had to be confronted. A crisis is an opportunity to deal with those problems that were long term, that had been postponed, but are become immediate. The protocol became a plan, an end of life care plan, and the third sector were given charge of it.

The Don Berwick report is just out -
"Acting on rare and outlying behaviors and on exceptional cases of poor performance – though necessary, will not create an overall far safer and better NHS; it cannot. A culture of learning can."
We’ll take learnings.
"Enforcement, even though needed, is not really the route to an overall ever better NHS – the NHS you want. Instead, our report says, bet on “learning"."
We’ll take more learnings.
"When things go especially badly, as happened, for example, in Mid Staffordshire, and public and private sentiment heats up, it can feel especially rough. And, at its worst, problems like that can hurt morale, as people lose sight of how great the mission is and of how hard you are trying to do what’s right."
It can feel more than "especially rough" for the victims and their families and "learnings" are insufficient and insulting. But that's just tough, ain't it, Don? What kind of vile little nobody is it who stoops to violating graves!
"A promise to learn – a commitment to act" - Don Berwick
Last time round, we made mistakes - next time round you won't find us out. Who is Don Berwick, dubbed the NHS Tsar?

  •      Donald Berwick
  • Donald M. Berwick is a former Administrator of the Centers for Medicare and Medicaid Services. Prior to his work in the administration, he was President and Chief Executive Officer of the Institute for Healthcare Improvement a not-for-profit organization helping to lead the improvement of health care throughout the world.... Wikipedia
  • Don Berwick - fellow Communitarian with Zeke, dubbed the deadly duo - quietly rolling out Obamacare the same way the LCP was quietly rolled out over here, and currently Democratic candidate for the Governorship of Massachusetts. Don Berwick, doctor and politician, an arrogance cemented in arrogance, a hybridised combination of Doctor Death and Grim Reaper...? If the cover sells the book, this won't even get off the ground...

    That's likely precisely what they want.

    It's a blockbuster and it's dynamite but they release it on a Friday and hope the 'breaking news' will focus on the Berwick report.

    The Baker Report really is getting buried beneath a landslide of other news -
    The counterfoils of MCCDs stored at Gosport hospital indicated that:
                 •  Dr Barton had issued 854 certificates from 1987

    The Baker Report covers a random sample of 81 of those deaths. That's roughly ten percent.
    Concerns about deaths at the hospital were raised in September 1998, when police commenced investigations into an allegation that a patient had been unlawfully killed on Daedalus ward. In March 1999, the Crown Prosecution Service (CPS) decided that there was insufficient evidence to prosecute. In 2001, a further police investigation took place, and again the CPS decided that there was insufficient evidence to proceed. In January 2000 an NHS Independent Review Panel found that whilst drug doses were high, they were appropriate in the circumstances.
    A complaint was made to the Health Service Commissioner against Portsmouth Healthcare NHS Trust about the death of a patient who had undergone an operation on a broken hip at another hospital and had been transferred in October 1998 to Gosport War Memorial Hospital 1998. The patient had died of bronchopneumonia in 9 December 1998, and the complaint was that the patient had received excessive doses of morphine, had not received reasonable medical and nursing care, and had been allowed to become dehydrated. The Commissioner undertook an investigation, at the conclusion of which he accepted professional advice that medical management had been appropriate and that the patient’s nursing needs had been systematically assessed and met. The pain relief was judged to have been appropriate and necessary for the patient’s comfort and the commissioner did not uphold the complaint.
    In March 2001, 11 families raised further concerns with the police about the care and deaths of relatives in 1998, and four of these deaths were referred for an expert opinion. In August 2001, the police shared their concerns with the Commission for Health Improvement (CHI), and CHI then began an investigation.
    The Baker Report makes reference to the the CHI (Commission for Health Improvement) report published in July 2002 -
    Arrangements for the prescription, administration, review and recording of medicines(Chapter 4)■ CHI has serious concerns regarding the quantity, combination, lack of review and anticipatory prescribing of medicines prescribed to older people on Dryad and Daedalus wards in 1998. A protocol existed in 1998 for palliative care prescribing referred to as the “Wessex guidelines”, this was inappropriately applied to patients admitted for rehabilitation.
    Anticipatory prescribing... The Wessex Guidelines, a precursor to the Liverpool Care Pathway... The Barton Care Pathway.
    4.4 The experts commissioned by the police had serious concerns about the level of use of these three medicines (diamorphine, haloperidol and midazolam) and the apparent practice of anticipatory prescribing. CHI shares this view and believes the use and combination of medicines used in 1998 was excessive and outside normalpractice.
    These three medicines used in the Wessex Guidelines are prescribed for use in the Liverpool Care Pathway.
    Notes on selected drugs 1. Morphine and diamorphineImportant sections of the review are concerned with the use of selected drugs towards the end of life. Brief notes about relevant drugs are included here for those who may not be familiar with them. The transition from the weaker to the stronger analgesics is usually described in terms of a three step ladder (Twycross et al, 1998), beginning with non-opioid analgesics such as paracetamol (step one), followed by the addition of a weak opioid such as codeine or dextromoramide (step two), the final step being the addition of a strong opioid. Morphine and diamorphine are both strong opiate analgesics. If the patient becomes unable to swallow, intramuscular morphine may be given, the equivalent dose being half the dose of the oral solution. However, diamorphine is preferred for injection because it is more soluable and can therefore be given in smaller volumes. The equivalent intramuscular or subcutaneous dose of diamorphine is one third the oral dose of morphine (Twycross et al, 1998). Thus, if a patient has been receiving 10mg of morphine oral solution every 4 hours (a total of 50 mg in each 24 hours), the equivalent dose of diamorphine administered subcutaneously by syringe driver would be approximately 17 mg in 24 hours. Agitation, confusion and myoclonic jerks occur as a consequence of opiate toxicity. These features may be interpreted as un-controlled pain, leading to the administration of more opiate medication. The consequences are increased sedation, dehydration and further toxicity (O’Neill and Fallon, 1997).
    "These features may be interpreted as un-controlled pain, leading to the administration of more opiate medication. The consequences are increased sedation, dehydration and further toxicity (O’Neill and Fallon, 1997)."   From the BMJ archives -
    "... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."
    The Liverpool Care Pathway throws Midazolam into the mix and recommends to consider withdrawing ANH (artificial nutrition and hydration)! The LCP is truly the LKP, a Licence to Kill People. The unanswered question:
    Dr. Philip Howard – One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.
    Midazolam and Diamorphine are administered and the patient is insufficiently monitored as Dr. Howard points out. This endangers patient safety. But, hey, it's a death pathway, ain't it? And so what if the training was insufficient so they couldn't tell the difference between opiate poisoning and agitation? The patient's gonna die anyway! 
    2. Fentanyl (Durogesic) is a strong opioid analgesic that can be absorbed through the skin, and is therefore administered by self-adhesive patches applied to the skin. The patch releases a defined dose per hour over a period of 72 hours, after which the patch should be replaced.
    The FDA (US Food and Drug Administration) cautions here upon the appropriate use of these patches.

    The Liverpool Care Pathway is a disaster of medical holocaust proportion. They have tried not to make a drama out of a crisis and to turn it to advantage. A policy rolled out has produced desired yet - seemingly - unrecognised results. Excess deaths...

    They have downsized care expectations. The British public has been successfully groomed. The policy of determining care to be 'futile' and downsizing care expectations has worked. The system has been a success. It is in place. It is working. Excess deaths... Murder on the NHS Express. But the chickens are going to come home to roost. Don't they have a duty to train people properly, to a sufficient standard, before they let them loose on the wards? Who's to blame, Bee Wee or Ellershaw? Who's going to own up? Who's going to be hauled over the coals? And finally...

    Washington Post - Lifestyle
    The Tricky Trio -
    We speak, of course, of firstborn Ezekiel “Zeke” Emanuel, 55, oncologist, bioethicist and health care adviser to President Obama; middle brother Rahm, 53, former White House chief of staff and mayor of Chicago; and baby Ari, 51, the Hollywood agent so powerful he inspired the character of Ari Gold on “Entourage.”

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