Saturday, 31 August 2013

Liverpool Care Pathway - There Are Many Pathways...

The many-headed Hydra has spawned a thousand children. And they're all jockeying for pole position.

Some, however, have simply donned a cape beneath which to conceal the uniform of their true loyalties.

This is Wirral Community NHS Trust - August 2013 and the "Wirral End of Life Care Plan" -

End of life care (EoLC) does not focus just on the last few weeks of life. Any person who may be in the last year of life due to a condition or illness is considered for EOLC; the above model; the Wirral End of Life Care Plan summarises the key stages for end of life care. All patients should be registered on the Gold Standard Framework (GSF) held by the GP Practice during the last year of life.
All community and specialist nurses are required to follow this protocol and comply with mandatory training in its implementation. This is not a personal care plan; this is the LCP.

The final page confirms this. The Control Record actually says -

"Change of name from Liverpool Care of Dying Pathway to Wirral End of Life Care Plan as instructed".

It's an Orwellian Newthink: "The EOLC programme aims to help individuals to live and die in a place of their choice reducing the number of people being unnecessarily admitted to hospital in the last weeks/days of life, and ensuring that the services they receive are appropriate to their needs and preferences whenever possible". 

That means if you've been selected for your GP EoLC list and you need an ambulance, don't call us; we'll call you. The Palliative Care Team will be right round with all the comfort care you need.

Page 2 leads into this - 
If these quality standards are not met then a rationale must be recorded in the patient’s health records
• All palliative care patients diagnosed as being in the last year of life and on End of Life Care Plan will have an Advance Care Plan in the form of a ‘Patient and Carer Assessment’ (PACA). The PACA is a comprehensive holistic assessment which is responsive to the changing needs and preferences of patients and carers 
• All patients must be offered a Preferred Priorities for Care Document and this must be recorded in the patients’ health records 
• All patients approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences and recorded in the PACA 
• All patients will have their pain assessed and recorded at every visit, preferably on the PACA to support continuity of care 
• All patients will have a nutritional screening assessment using the Malnutrition Universal Screening Tool (MUST) to identify patients at risk of malnutrition according to the patient’s clinical needs. For patients identified at risk following a MUST assessment, a nutritional care plan will need to be in the records 
• All patients should have medication prescribed for ‘anticipatory prescribing’ as per Wirral Care of the Dying Guidelines according to patient’s needs. 
• All patients approaching the end of life who may benefit from specialist palliative care are offered this care in a timely way appropriate to their needs and preferences 
• The PACA should include the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) status of the patient. 
• All informal main carers must be offered a carer assessment, if carer declines this must be documented in the patients’ health records 
• All patients will be commenced on the Wirral End of Life Care Plan. 
• All patients will have a syringe driver set up within 4 hours 
• All patient records will have evidence of Out of Hours referral updates at least monthly 
• All carers will be offered bereavement support visit
The PACA is an Advance Directive. This is an holistic assessment reached conjointly with Patient and Carer(s), hence PACA. This is not to be confused with 'holistic' as it is used in so-called 'alternative medicine', however.

An assessment is made that is no better than a forecast - a guess - that EoL is at hand and discussions proceed on that basis between the groomer (the Healthcare Professional) and the groomed (the Patient and Carer(s)).

Ongoing discussions will add to and modify the PACA. 

Beware what you agree to... When the end is at hand you may wish that you didn't.

Wait a minute. The Wirral says all palliative care patients will have an Advance Care Plan -
All palliative care patients diagnosed as being in the last year of life and on End of Life Care Plan will have an Advance Care Plan in the form of a ‘Patient and Carer Assessment’ (PACA)
Will. Even should they decline to...? There is a provision in the document for if the carer(s) should decline and that this should be noted but not if the patient should decline.

Upon implementation of the Wirral, a driver will be set up within 4 hours. 

This is a nightmare version of the LCP.

If Kathleen Vine had been put on this, she wouldn't have woken up...
Trigger question for assessment to decide if the patient may have end of life needs regardless of diagnosis
The surprise question, ‘’ Would you be surprised if this patient were to die in the next 6-12 months’’ – an intuitive question integrating co-morbidity, social and other factors (Gold Standard Framework, 2008).
This is not science or medicine; this is quackery. This is the medical equivalent of stepping out of the realm of Astronomy into the realm of Astrology. To make such a decision to downsize healthcare options on the basis of a 'surprise' question is no more than a weather forecast. But that's the so-called Gold Standards Framework for you...

This is the LCP OTT.
The advance care planning in the community ‘insight score’ can be completed at initial assessment or at a later date if patient is not aware of prognosis or reluctant to talk about end of life care. However, this does not stop initiating appropriate conversations for advance care planning or end of life care
This is grooming. The next paragraph in the document on Frequency of Contact demonstrates this - 
"regular ongoing visits promote proactive management of patient care which evidence suggest helps to reduce unnecessary hospital admissions".
Regular visits reinforce the grooming process. The patient is groomed by nursing staff themselves groomed to comply with and agree to the ethos.

This is a cult.

There will be 'guided discussions'.
If patient and/carer are finding it difficult to talk about end of life care issues after a number of visits, regarding their concerns or their PPC, seek advice from the End of Life Care team as further specialist advice may support future advance care planning and timely communication.
If the situation arose - as it did with Kathleen Vine - that they needed a bit of extra persuasion that dying was not a possibility but a certainty, they'd send in the heavy grooming squad.
"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely - and he came in and he was sort of asking us if we'd thought about the funeral and how we were going to tell our daughters, and just, sort of, getting us to talk about it, I suppose. And I was saying, I just can't believe it. You know, she came in with a dislocated shoulder ; we're now being told she's dying. Nanny woke up at that point. And she had a full on conversation with him. She actually flirted with him. You know, she was saying, ooh, aren't you lovely? You've got lovely eyes. Surely, that's not a dying person. She's chatting you up, asking if you'll feed her... This, this can't be right, you know."[ Laugh...] - Kathleen Vine's granddaughters  The Report
The Oncological ECOG tool is also applied. This is a case of a tool being misapplied, surely, to make imperative the palliative response!

The Pathways are rolled out across non-hospice settings, intended for use in all cases, of non-cancer and non-terminal diagnoses also. The patient is determined to be and is 'diagnosed' as - dying! How may an Oncological tool be used in such a setting?

Uncertainty is become certainty and the patient is doomed.

Page 7 leads into this - 
 The PACA should include the CPR status of the patient. This decision should have been discussed at the GSF Practice meetings or with the GP.
‘’If the patient has an irreversible condition where death is the likely outcome the patient should be allowed to die a natural death and it may not be appropriate in these circumstances to discuss a DNACPR decision with the individual’’ 
(Trust Policy ‘Do Not Attempt Cardio Pulmonary Resuscitation’)

Presumably, in this case, the PACA has been agreed to and contains the relevant DNACPR status of the patient and this is positive. In such a case, the above-stated Trust Policy may not be seen to be at variance with legislation or policy.

However, such a statement made so readily and forthrightly is foolhardy and fraught indeed given this GMC ruling -
16 July 2012 
The General Medical Council has ruled that the failure by a doctor to consult a patient and their family before imposing a Do Not Resuscitate Order (DNR), a failure to record clear reasons for a DNR and an inappropriate use of DNR are all reasons  “capable of amounting to impaired fitness to practise”.
The decision follows the case of Barbara Evans who died in December 2007 at the age of 84. 
Leigh Day
And yet...

Well, what have they to fear? They have executed or been a party to a medical holocaust and they have, apparently, got away with it.


Well, this is convenient -
Managing expected deaths out of hours requires a co-ordinated approach across all agencies. To help avoid any unnecessary stress or inappropriate calls to the police or ambulance service, the Wirral Coroner’s Office has written a supporting letter attached to each Wirral End of Life Care Plan.

There has also been a politically correct 'equality assessment' to ensure there is no possibility of any discrimination or exclusion of any 'protected characteristic' and that this veritable tool may find universal benefit to all.

That makes it all okay, then.

This truly is a nightmare version of the LCP.

This is a mishmash LCP.

It is still the LCP.

Mr. Lamb...?



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