Monday, 2 September 2013

Liverpool Care Pathway - The Pathway Is Legion

There’s safety in numbers. We can’t go after them all. And the Pathway is legion for it is many...

To put it bluntly, they have killed people and no-one has batted an eyelid. How can this be? How can this be?

The Amber is going for Gold

Dr. Adrian Hopper and his team from Guy's & St. Thomas' have gone global and coasted off to OZ to address a conference in connection with rolling out Amber at nine sites across New South Wales (NSW).

Amber has been embraced by the NSW Government which has published a document, Advance Planning for Quality Care at End of life. This is an EoLC Action Plan for 2013 - 2018 which discusses downsizing care options but calls it 'End of life conflict'.

What is 'end of life conflict'?
End of life conflict 
 End of life conflict is defined as disagreement which occurs about the goals of care or treatment decisions at the end of life and where such conflict is not resolved by the usual recourse to time and further discussion between the patient, the family and the treating clinicians, as appropriate 
(NSW Health 2010, Conflict resolution in end of life settings project report).
The point of foreseen conflict is on the issue of what is considered the appropriate response - the palliative or the curative.

When is the point of 'End of Life' reached? When the diagnosis of 'dying' is made...?

The document discusses the need for 'conflict resolution'. In what context...?
  • Potentially avoidable conflicts between families and the health care team, or within the health care team, about the best course of treatment and care for the dying patient
  • Care being delivered in acute settings when better patient outcomes could be delivered in supported community or home environments
Here, it is foreseen that members of the medical team may actually break ranks and support a curative option but it is insisted upon that the non-acute setting is the preferable option. For whom?

Medical treatment is intended to intervene to promote recovery. That is the upsize perspective. The downsize perspective is that it prolongs the dying process and 'forestalls death'.
Life-sustaining treatment
Life-sustaining treatment is any medical intervention, technology, procedure or medication that is administered to forestall the moment of death, whether or not the treatment is intended to affect life threatening diseases or biological processes. These treatments may include, but are not limited to, mechanical ventilation, artificial hydration and nutrition, cardiopulmonary resuscitation or certain medications (including antibiotics).
Conflict resolution through discussion grooming -
Some health professionals in NSW have expressed concern that discussing and documenting end of life concerns with families will lead to family complaints, conflicts about end of life decisions, and legal exposure. Sensitively conducted and inclusive conversations with patients and families and thorough documentation generally reduce the likelihood of family complaints and risk.
The important context to remember is that Amber was responsible for upsizing LCP quotas where it was used.

The net is being trawled wider.


What is to be done?
  • Improve identification of dying patients using the Between the Flags Program.
  • Pilot an End of Life Observation Chart based on Between the Flags Program documentation that helps monitor the quality of care provided to dying patients, including escalation for clinical review.
And hold Death Audits, just to make sure everyone is dying to plan.

The Between the Flags program is a standardised program devised by the Clinical Excellence Commission (CEC) in collaboration with the NSW Health quality and Safety Branch (QSB) to identify and early manage deteriorating patients. This net is now become a trawl just as similar schemes are being employed here.

And the Pathway is Legion -

The SPICT now has its own website which depicts a watermarked June 2013 version. This has been edited in the following manner:

Eating less; difficulty maintaining nutrition.
…………Choosing to eat and drink less; difficulty maintaining nutrition

Unable to communicate meaningfully; little social interaction.
…………No longer able to communicate using verbal language; little social interaction.

Kidney failure due to another life limiting condition or treatment.
…………Kidney failure complicating other life limiting conditions or treatments.

Has needed ventilation for respiratory failure. 
…………Has needed ventilation for respiratory failure or ventilation is contraindicated.

The unwatermarked July 2012 version is still available online. 

The CPPPC is being rolled out in five regions in Belgium -
We are starting the implementation of a Care Pathway of Primary Palliative Care (CPPPC) in five regions in Belgium, to be used in a first phase by the primary health care team, aiming to extend it later on by hospital staff. This CPPPC will start with early identification of palliative patients by using the Surprise Question and the Supportive and Palliative Care Indicators Tool. The second step is individualized advance care planning, aiming to design an individual care plan that grows over the time, fed by multiple discussions with all stakeholders taking care of the palliative patient, including hospital staff. We hope that, from a long-standing relationship and “knowing the patient’s and family’s wishes”, this way of providing care will lead to a better palliative as well as end-of-life care, both in the outpatient and in the inpatient settings .
The CPPPC, in the same manner as the LCP and Microsoft Windows, is being tested 'live'. It is untrialled and untested.
We believe that to evaluate a complex intervention like our Care Pathway it is not enough to find associations and correlations in quantitative databases. We will evaluate the CPPPC by quantitative means, but partly inspired by the LCP cautionary tale, we will also interview users of our Care Pathway (health care professionals, patients and family members) to find the specific contexts in which and psychosocial mechanisms through which the CPPPC works the best, and in which it doesn’t work.
Microsoft uses the punters to iron out the issues. Here, they will use the corpses. These are people!

Wait a minute. The Surprise Question, the Prognostic Indicators...

The LCP by any other name might smell as sweet the sweet smell of death.

And the CPPPC is an 'evaluative' tool. Might this form part of the randomised trial of the Liverpool Care Pathway proceeding in Flanders' Fields...?

Whither the Dundee Dignity Care Pathway? This has travelled afield also -

The British Journal of Community Nursing discusses the implementation of this 'care intervention'.

While the All Ireland Institute of Hospice and Palliative Care is bringing psychometric skills into the community setting to give the blarney that extra edge and has recruited a Project manager to oversee this -

Project Aim
The aim of this project is to implement and evaluate a dignity care intervention that will be delivered by community RGN’s, public health nurses (PHN), and specialist palliative care nurses based in a community setting to help conserve the dignity of people at the end of life.It is anticipated that 45 PHNs/RGNs in Dublin South Central will receive training in Dignity Care Intervention (DCI); 51 PHNs/RGNs in Dublin South City, 30 PHNs/RGNs will be trained in Limerick and 30 PHNs/RHNs in Wicklow.

The Summer 2013 issue of GP Exchange at Norfolk Community Health and Care NHS Trust reports -
We have been awarded £100,000 from Skills for Care to bolster our ‘Six steps to success in end of life care’ training course. The course is aimed specifically at supporting care home staff to be more confident and competent at assessing and delivering palliative care.
The Six Steps to Success became infamous last  year using gross educational material such as this...

NHS Calderdale CCG is tendering for an Integrated End of Life Care Pathway -

Integrated End of Life Care Pathway.
Published by:
Publication Date:
Application Deadline:

Deadline Date:
Deadline Time:
Notice Type:
Contract Notice
Has Documents:
General Overview and Objectives of Services.
The simplified end of life care pathway for Calderdale, expects the service to provide and support the delivery of high quality, evidence based, safe patient centred care.
It is vital to the success of the proposal that a thorough awareness raising programme be implemented across all professionals in the end of life care pathway. This will ensure maximum output is achieved. It is vital that all providers including the Calderdale CCG are committed to the education process in order to fully realise the patient and financial benefits.
To support implementation of this pathway, Calderdale CCG will commission an end of life facilitator to embed end of life tools, champion key quality standards across the pathway and coordinate training and education to meet local needs. There is currently no dedicated end of life care facilitator within the area. Key tasks of the facilitator role would include an Out of Hours Community Nursing Service. This would involve a dedicated nursing team, which will provide planned and crisis visits out of hours, as well as telephone support to patients and carers, and generalist palliative care advice and support to other professionals such as care home staff. It is proposed that this team is in addition to the existing structure and will be ring fenced for end of life patients.
The increasing complexity of patient needs resulting in increased demand on staff time is the basis for the proposed uplift in staff numbers. It is crucial for the out of hours service to be able to double up on staff numbers to ensure staff safety but also to deliver more complex care in response to the patient's needs.
The Out of Hours team will facilitate and support discharge out of hours from Calderdale and Huddersfield Foundation Trust. The discharge will be facilitated safely with the individuals consent and will work in collaboration with existing care providers. The team will also work with existing care providers and ensure handover notes are in place for discharges in-hours. This will contribute to a reduction in length of stay in terms of acute bed day's and will ensure more patients die in their preferred place of care.
This service will provide end of life patients and their carers/families with:
Support for community staff who need assistance/education in order to provide palliative care;
Provision of advice and support re specialist palliative care to existing clinical staff;
An integrated approach to care, working alongside existing community and primary care team. The patients GP will retain clinical responsibility.
Receipt and triaging of calls from patients and their families registered with a Calderdale GP.
Response to crisis calls by providing crisis nursing hands-on care including physical symptom management, psychological and social support.
Telephone advice and reassurance.
Follow up telephone support or home planned visit for patients identified by their key worker when other planned services are not available.
Planned nursing care to facilitate a patient's choice to stay at home.
Carer support immediately after death.
The objectives of the service are:
To support the existing District Nursing teams and step in when more specialist services are required, through the provision of advice and practical support for more complex situations
To improve the quality and clinical effectiveness of care delivered at home to end of life care patients and their carers/families in Calderdale and to limit the physical and psychological suffering that patients and carers experience at end of life; maximising quality of life through the provision of rapid and effective care and support.
To ensure speedy access to end of life care is met in the community in a timely manner.
To decrease the length of time between seeking assistance and accessing specialised palliative care services in order to mitigate crisis events.
To act as a flexible, responsive service that will react to unscheduled demand out of hours.
To deliver a consistent response and comprehensive communication with other providers for example Hospices, McMillan Services and District Nurses.
To support the transition from care provided in an acute hospital setting to home in a safe and timely manner.
To educate patients and carers on self-care and the best use of services.

The NCPC Reports -
A Leadership Alliance for the Care of Dying People is being set up by NHS England.
The Leadership Alliance for the Care of Dying People (LACDP) will operate under the chairmanship of Dr Bee Wee, National Clinical Director for End of Life Care at NHS England, to respond at a strategic and system-wide level to the report following the independent review of the Liverpool Care Pathway (LCP).

Everyone is going for pole position. No-one wants to be left on the sidelines.

The N&MC reports on this also.

They are focussed on ensuring...
high quality, compassionate care and support for all those who are dying, as well as their families and friends. [Claire Henry and Anita Hayes]
Mail Online

Should they not refocus?

They are themselves responsible for many of these poor people going to an early grave -

Tens of thousands of patients are dying needlessly in hospital every year from kidney failure linked to dehydration, NHS officials have revealed.

They calculate that up to 42,000 deaths a year would be avoided if staff ensured patients had enough to drink and carried out simple tests.

NICE, the NHS watchdog, is today issuing guidelines to staff to help them prevent deaths from the condition – known as acute kidney injury – which is common in the elderly and patients with heart disease, diabetes and blood infections.

They need guidelines to provide nutrition and hydration?

They are a death cult.

And they are legion...

1 comment:

  1. I commend you for the amount of work you have done and how stalwart you have been in pointing out the injustice done to your own mother. I want to assure you that you are not alone and your blogs do not go unnoticed.

    You have shown that there is a systematic culling of the elderly that despite changes in name, such as LCP to something else, means that the culling goes on relentlessly.

    I hope you have the strength to continue your work because the world needs you and your kind.