Friday, 6 September 2013

Liverpool Care Pathway - Don't Call The Ambulance!

An outcome is not at all the same thing as a consequence and is not a standard therefore by which an intervention may be assessed.

That is a plain and simple truth. Obviously, stating the obvious may seem at first sight to be overstating the obvious...

Sadly, those oblivious to the obvious oft require it to be pointed out to them...

Tweets from the 12th Australian Palliative Care Conference -
Josh Hatton ‏@JCHatton -"Introduction of an end-of-life care pathway pilot program produced reduced return to hospital to die rates from 21% to 1.9%. #PallCareConf"
Catherine Walshe ‏@cewalshe -"@JCHatton Interesting? Pathway focused on what - care at home/community? What aspects to pathway?"
Josh Hatton ‏@JCHatton -"@cewalshe Residential aged care. 3 trajectories based on predicted life expectancy. Fiona Israel and Deborah Parker lead the studies." 
Josh Hatton ‏@JCHatton -"For more on Pall Care Case conferences (and hopefully end of life care pathways) #PallCareConf"
Am I missing something here…?

If you don't call the ambulance, you don't get taken into hospital.


The Queensland Government recommends that the pathway framework should include -
Mechanisms to facilitate GP support to provide end of life (terminal) care 'in place'. 
This is already in place in the UK.
In the Palliative Approach Toolkit, a flowchart mechanism is used to filter all new and existing residents for the palliative trajectory.
There is featured an appropriate but ominous monochrome picture of a pathway.
Nutrition, hydration advice is given:
• Artificial nutrition or hydration is generally considered a life sustaining measure or medical treatment.
• At the end of life, it is important to remember that the person’s body is beginning to shut down because of the disease and the dying process, not because of the absence of food and liquid.
• Family members may find it difficult to distinguish between ‘not eating’ as part of the dying process and ‘not eating’ as bringing about the dying process.
• Just because something is reversible does not mean it should be reversed.
The resident being diagnosed with the condition of ‘dying’ may also be observed to be ‘living’; the basis of the diagnosis is the presence of three or more symptoms that may or may not be particular to nor even present ultimately in a condition of death and yet, by that very diagnosis, must prejudice the outcome in favour of such a conclusion.
Palliative care is  defined as “care provided for people of all ages who have a life limiting illness, with little or no prospect of cure, and for whom the primary treatment goal is improved quality of life.” []
The resident is not being diagnosed with a ‘life limiting’ illness, but with ’dying’. As with the LCP, if the resident presents in a manner determined as ‘dying’ they are commenced on the pathway.
Implementation of the Residential Aged Care (RAC) Pathway is via a single authorisation - from the GP (General Practitioner). Interim authorisation may be obtained from the Palliative Care Medical Officer (PCMO); the Palliative Care Nurse Specialist (PCNS); or Senior RAC Facility Registered Nurse (RN). Authorisation may be verbal but should be confirmed in writing on the RAC document within 48 hours.
[If death should take place before that written confirmation is given is a factor that does not appear to be contemplated...]
If possible, the resident/representative should be involved in this process, but the final decision is a clinical one.
[May not the resident seek a second opinion?]
“Consent has its ordinary meaning. To have legal effect, a person’s consent must be given freely and voluntarily so, for example, it must not be given because of another person’s pressure or coercion. Consent may be implied by a person’s conduct. In some circumstances, consent requires particular legal formalities (for example, the completion of a valid Advance Health Directive).” [BRISBANE SOUTH PALLIATIVE CARE COLLABORATIVE]

In some cases, if their condition improves, the resident may be taken off the pathway. A reassessment should occur [in line with the LCP] every three days.
[The median time to death on the LCP is 33 hours, so why every three days? Is the death cult also a religious cult? “And on the third day…”]
The reassessment is basic. ‘Inappropriate’ observations will not be made.
It is appropriate to start the pathway if three or more of these signs are present –
  • Rapid day to day deterioration that is not reversible.
  • Requiring more frequent interventions
  • Becoming semi-conscious, with lapses into unconsciousness
  • Increasing loss of ability to swallow
  • Irreversible weight loss
  • An acute event has occurred, requiring revision of treatment goals
  • Profound weakness
  • Changes in breathing patterns

‘Inappropriate’ interventions (BSL, blood pressure monitoring) are stopped/not started. [This is the LCP.]
‘Non-essential medications are withdrawn.
However, interventions are stated to be interventions; this is not just an innocuous document.
PRN meds are ordered as per guidance.
It is interesting to note here that, according to an Australian Commission National Audit report published 2011,
There was a 36% PRN frequency error rate (and which could be a particular focus of attention) in the matter of designated medicine name, route, dose and frequency sections
There were duplication errors – It is unknown if the duplication errors are regular and PRN orders for the same drug or two regular orders on separate medication charts. The clinical significance of these errors is unknown
There were PRN dosing and frequency errors – Data were missing for PRN maximum doses and issues raised about denominators
The Western Australia Guidelines for safer prescribing advise
 5.1 As required (“PRN”) Medicines
Prescribing: The medical officer must write: 
 Dose and hourly frequency. “PRN” (pre-printed) alone is not sufficient 
 Indication and maximum daily dose (ie Maximum dose in 24 hours) eg Paracetamol 4g/24 hrs 
The ‘Max dose/24 hours’ prompt indicates the total amount of the medication which may be administered in 24 hours for PRN doses only. The maximum daily dosage should not be exceeded for that PRN medicine. 
Prescribers should exercise caution when prescribing PRN medicines and check the regular medications section for possible duplicate orders. Administration:The actual dose given must be recorded as well as confirming the route. The person administering each dose is responsible for checking that the maximum daily dosage will not be exceeded

This is now discussed with the resident/representative. [Too late now to ask for a second opinion.]
Future care plan is discussed (hospital transfer, antibiotics); ‘Not for Resuscitation’ order agreed; spiritual requirements; preferred funeral director.
[It’s your funeral…]
The document then provides Comfort Care Charts sufficient for four days monitoring. 
Followed by Further Care Action Sheets
Infusion device is removed and returned.
Discuss grieving issues with resident’s representative.

Advance Health Directives provide legitimacy and cover to proceed with confidence.

Designing early trajectories implants early on an acceptance of life-limited prognoses and acceptance of palliative rather than curative options. [After all, what's a few weeks, few months extra life, anyway? It's neither here nor there.]

This is happening in the UK. This is all about changing minds, downsizing care expectations so you don't need to call that ambulance.

And the LCP juggernaut has broken up into a myriad of splinter cells.

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