Thursday, 31 October 2013

Liverpool Care Pathway - The Communitarian Nudge

How to subtly alter perception and influence people. The psychology of grooming...

This is a free and democratic society. In a free and democratic society, a free electorate is canvassed and expresses its free opinion at the polls. Or does it...?

This is February 24, 2009.

This is Cass Sunstein. This is Time

Consider government standards for allowable amounts of arsenic in water, a topic Sunstein has written about. A standard set at 3 parts per billion will save more lives than a standard set at 10 parts per billion, but it will also cost more to achieve — a cost that will in turn be passed on to consumers in their water bills. If it can be shown that the more stringent standard would result in saving 10 lives per year, how much would society be willing to pay to achieve that? Ten million dollars? A hundred million? A billion? 
Making that calculation, of course, requires placing a dollar value on human life, which can mean getting into some sensitive areas. Sunstein has written in support of what some people call the "senior death discount," the statistical practice of taking into account years of life expectancy when evaluating a regulation. By that measure, for example, it would be harder to justify spending to correct an environmental hazard that posed more of a threat to the elderly than one that was more dangerous to children, who have many more years ahead of them. 
In his voluminous writings, Sunstein (who is not giving interviews before his confirmation hearings) has repeatedly defended the idea of a strong regulatory state.
It is harder to justify spending to correct an environmental hazard that poses more of a threat to the elderly than one that is more dangerous to children, who have many more years ahead of them...
This is fundamentalist Communitarian Complete Lives thinking. Readers of these pages will be very familiar with Zeke Emanuel's Complete Lives System. It was in January of that year, 2009, that Zeke had his infamous Communitarian system published in The Lancet.

Cass, the King of Nudge, long-time Obama buddie...


This is Obamacare. This is the EoLC Strategy.

Here they are, all pals together, supplying input here, across the pond and, via nudge, over on the mainland (EU)...

Cass, Don Berwick, Simon Stevens, Zeke Emanuel of the Tricky Trio Emanuel Bros.

The Sunstein groupies in the Cabinet Office BIT Team use a SMART mnemonic -
EAST (Easy, Attractive, Social, Timely).
They all love SMART.

"We believe that "people in the last days of life should be identified in a timely way and have their care commissioned, coordinated and delivered in accordance with their personalised care plan, including rapid access to holistic support, equipment and administration of medication". (NICE Quality Standard 13, 2011)"
Are SMART objectives used in office and in industry really an appropriate tool and properly suitable for a care setting?

Rapid access to holistic support...


Getting the nudge in the required direction.

That's the psychology of grooming.

Essential reading -

This Blog.

Liverpool Care Pathway - A Day For Life And For Living

Tomorrow, take time out to celebrate a very special Life Café...

Because, tomorrow, it's All Hallow's Day!

Tonight, All Hallow's Eve (Halloween), the ghosts and the ghoulies make mayhem and mischief and have their last fling to run riot abroad...

But 1st of November, all Hallow's Day, is the Day for Life!

Don't let them assimilate everything that is positive and right. They have taken the word 'holistic' and perverted its meaning for their own purposes. 

Your GP does not practice 'holistic medicine'. Your GP will alot you a time slot and discuss only one symptom and send you on your way. That is not holistic medicine.

Medicine is concerned with the treatment of diseases and injuries; of matters which affect well-being and health. It would generally be accepted that medicine is the science and art of dealing with the maintenance of health and the prevention, alleviation, or cure of disease. The focus of holistic medicine will be to assess the person and not just the symptom(s) toward recovering and restoring an equilibrium of health.

Not all is possible but, always, it is to strive to do no harm and to act with best intent.

One thing your GP is skilled in - courtesy of the 'tools' provided and made available, such as the GSF and the Barton method - is diagnosing EoL and recruiting for the death lists. Then, suddenly, they find holism...!

This is Wirral Community NHS Trust - August 2013 and the "Wirral End of Life Care Plan" which is just the LCP by another name -
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 approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences and recorded in the PACA 
This is the mission message from

"I Support The Liverpool Care Pathway"  
I support the APPROPRIATE USE of the Liverpool Care Pathway (LCP) for the Dying Patient. For the RIGHT patient, at the RIGHT time with CLEAR COMMUNICATION and TRANSPARENCY of what the pathway actually is - holistic assessment of a dying patient.

The patient is placed in a box labelled 'dying'...
Oh, the joy of living, sweeter music they're giving
Than the singing bird you heard before...
- Cliff Richard
There's always time for Life Café. Have yours on November 1st, All Hallows Day.

The evil spirits have had their last fling (Halloween) and now the good spirits come to chase them away!

Celebrate the lives of loved ones, present and passed on...

...because life is precious, and living matters.

Further reading -

Liverpool Care Pathway - And Can You Say That This Is Not A Death Cult...?

Liverpool Care Pathway - Nudge, Nudge, Say No More...

The BIT Team back-room boys and girls are hard at work to reshape and remould public opinion.

This is the Bit Team
Over the past week or two there has been lots of coverage of a new team in the White House that will look to apply lessons from behavioural sciene to public policy. The US team will be headed by Maya Shankar, who met members of BIT in Washington to discuss how we will exchange ideas and share research – a process first started by our Director, Dr David Halpern, and Prof Cass Sunsein while Cass was at the White House.
On Friday, TIME Magazine ran an article looking in more detail at the successes we have had in the UK and overseas. The article features discussions with Professor Richard Thaler, who is on our advisory panel, BIT’s Deputy Director, Owain Service, and also Pelle Guldborg Hansen and Jesperson from iNudgeYou who have done some great work in Denmark.
We wish Maya much success and look forward to working closely with her and her team.
This is from the Time article –
When a White House adviser sent out an e-mail last month announcing that she was looking to hire social scientists to study human behavior and design public policy based on social experiments, right-wing critics were aghastBarack Obama was going too far again. 
The inspiration for Yale social scientist Maya Shankar’s team, she said in her note, is Britain. It’s in the Old World that the White House has gone looking for something new, calling a gang of consultants in the United Kingdom an inspiration. There, the so-called Behavioral Insights Team has taken a controversial philosophy and found solutions from lowering energy consumption to increasing tax collection. 
The squad was established a mere three years ago, following Prime Minister David Cameron’s ascension to power. Referred to in Whitehall patois as the nudge unit, the team was inspired by the 2009 bestselling book, Nudge: Improving Decisions About Health, Wealth and Happiness by University of Chicago professor Richard Thaler and Harvard Law professor Cass Sunstein. Cameron’s political mandate was simple: influence British policies by constructing cheap, shrewd and local solutions to social problems across governmental agencies. 
The nudge unit appears to have succeeded where one of its inspirations could not. During the first three years of the Obama administration, Sunstein led the Office of Information and Regulatory Affairs where he was charged with approving every new regulation the government issued based on cost-benefit analysis. Sunstein has written that his efforts were hamstrung by a political climate suspicious of his ideas. Last year several important regulations were halted before the presidential election and Sunstein’s subsequent book, Simpler: The Future of Government describes the difficulty of new thinking into government. With an entire team to focus on streamlining costs and regulation across the government, the new team is aiming to improve on Sunstein’s record. 
Simple social experiments circumvented difficult-to-pass legislation, altered peoples’ behavior and saved money.
This is about changing minds and saving money...

Very interesting.
Bridgette [Bridgette madrian], an expert on pension defaults, is also now interested in whether unnecessary and unpleasant end of life over-treatment could be reduced by encouraging people to make advance directives at key junctions in life, e.g. at 65 when they become entitled to medicare in the USA
-   Bit Team.
This all sounds very familiar and very ominous...

At work on both sides of the Pond to advance an economic solution to...? 

Wednesday, 30 October 2013

Liverpool Care Pathway - Redefining The Options

Redefining, redefining, redefining... The key to downsizing?

They used to say, "Catch it early and it can be treated." No more...

This is Shots Health News from NPR

The National Cancer Institute convened a group of specialists last year to look at the problem of overdiagnosis and overtreatment of cancer. One idea: redefine what gets called cancer.
A new definition would be much narrower. The institute hopes to keep the word "cancer" out of some diagnoses to help calm patients' fears and minimize unnecessary treatments.
We won’t call it cancer; we’ll call it something else. It ain’t what you say; it’s the way that you say it...

We've heard that before.

The NPR article provides a link to an interesting submission to JAMA (Journal of the American Medical Association) which discusses problems of diagnosis in early detection. Herein, lies the real problem...

Readers of these pages will know of attempts to redefine death. Readers of these pages will know of attempts to redefine care. In that context, any attempt to redefine disease, such as cancer, must be viewed with caution and distrust.

This is particularly the case when Dr. Otis Brawley, the NPR interviewee, discusses a case in point of a gentleman diagnosed with prostate cancer...
And given his age, which was in his 70s, it's something that almost all doctors agree should be watched as opposed to treated. 
Therein lies the real problem. And there is more afoot...

There is currently a mega-huge, local-level, countrywide propaganda campaign by Macmillan -

Lancashire Telegraph
Express and Star

A CANCER charity has called on ministers to help more terminally-ill patients get their final wish to die at home, rather than in hospital...
 - The Telegraph and Argus

A national charity claims 250 cancer patients in Bradford died in hospital beds last year when they would have preferred to die at home...

Almost 2,000 people in the Westcountry were denied their last wish to die at home last year and instead ended their days in hospital...

Exeter Express and Echo

Southern Daily Echo

MORE than one thousand cancer patients in Hampshire are denied their last wish to die at home every year, according to new figures...

Macmillan Cancer Support has found that around 1,175 people across the county die in hospital each year despite their final wish to die in the comfort of their own home...
Bedfordshire News on Sunday

EACH year around 260 cancer patients in Bedfordshire who die in hospital beds wanted to die at home according to new figures released today by Macmillan Cancer Support...

In addition, Macmillan are doing a mass survey of Nursing Times subscribers.

Professionals are being asked to take a survey to provide feedback to Macmillan of their own experience in clinical practice.

Which means Nursing Times have facilitated Macmillan with access to personal email data they hold... 

Macmillan are promoting the Death Lists -
Hillingdon CCG

In 2008 28% of people in Hillingdon died in their usual place of residence. This did not align to the 50% of people who indicate that they would like to die in their own home. The first three year End of Life Care Strategy for Hillingdon – entitled ‘Making End of Life Care Everybody’s Business’ was agreed by Partner organisations and over the subsequent years progress was made so that by 2011/12 32% of people were dying in their usual place of residence.

In 2012/13 we aimed to increase this by another 5% to 37%. This has been achieved, in part through the introduction of an electronic patient record for patients who are identified as being in the end of life phase of their illness. The register, Co-ordinate My Care (CMC), is linked to the 111 programme in London. Hillingdon was one of the first implementers of both 111 and CMC.

The 2013/14 scheme has been planned to increase the percentage of people dying in their usual place of residence by a further 8% to 45%. Evidence from the National End of Life Department has shown the most progressed areas of the country are hitting 50%. End of Life Care (EoLC) is complex and buy in from all stakeholders is required. Improvements in delivery of EOLC require facilitation led through a change of culture. There is currently a lack of coordination between a number of organisations providing End of Life Care. We are utilising CMC and have been an early adopter of the system but need to enhance the involvement of primary care practitioners in its use. The following key issues are the main areas that need to be addressed:-

* Lack of Education/awareness of End Stage Prognostication in General Practice

* Advanced care planning is not widely adopted.

* EOLC register does not reflect true numbers of patients in the end of life phase
* CMC integration will enable co-ordination of end of life care by facilitating improved communication. Primary care is not fully utilising CMC

* Culture change

* Patient centred care and choice.

* Lack of integration.
As a result of the above, the Macmillan charity have suggested the possibility of pump priming a pilot to trail the introduction of a GP lead facilitator post. The only commitment required from the CCG will be a letter of support in principle for the post and a willingness to evaluate the effectiveness of the post. This Business Case has been developed as a partnership project between partner organisations (Macmillan, CNWL and THH) delivering End of Life Care services with the aim of establishing a GP Macmillan Post in Hillingdon. 

Redefining is the new signposting to downsizing care.

Tuesday, 29 October 2013

Liverpool Care Pathway - Still Pushing For Amber

He's been pushing the Amber Nectar in Oz... Back from his tour of NSW, it's the Brit 'Daktari' with the X-Factari, Adrian Hopper!

This is Hospital & Aged Care

Dr. Adrian Hopper and his excellent team of roadies from Guy's & St. Thomas' have been a big hit.
Dr Hopper, from Guy's and St Thomas' NHS Foundation Trust in London, where he is the Deputy Medical Director for Patient Safety, visited Australia recently on behalf of the NSW Clinical Excellence Commission.
Back home, the UCLH Board has favoured Amber -

The Board noted the reports including that the issues raised about end of life care had largely been addressed by funding for the AMBER care bundle and for training. Care of the elderly services were being reviewed by Jonathan Fielden in order to provide an expanded and improved service at UCH. A review of the hospital as night system is also being undertaken with the aim to improve the support being provided to ward sisters.

Amber was responsible for upsizing LCP quotas where it was used.
What does Amber mean? This is the Royal Surrey

Sometimes, despite our best efforts, patients do not respond as well as we would expect to treatment and their recovery may be uncertain. By identifying a patient as AMBER we can make sure that all our staff know about the patient’s condition and are working together to give these patients the best possible care and support. 
Downsizing care options.

This is Westminster Health Forum

Keen on pushing Amber...

Following the review of the Liverpool Care Pathway (LCP), what should be the next steps for the delivery of personalised care plans and for developing a system‐wide approach to improving quality?

The Agenda favours Amber with a mention.

In Oz, they favour conflict resolution.

What...? Is Canberra sending some well-heeled peace envoy off to the Middle East?
No, it's doctors resolving EoLC issues.

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...?

Everyone gets it in the end. Or those of us 'unfortunate' to live too long to get it.

Yes, it's that life-limiting condition we call Old Age and one of the factors taken into consideration. Old Age is, effectively, a terminal illness!

Essential reading –

Monday, 28 October 2013

Liverpool Care Pathway - There's Life In The Old Dog Yet

How to cut social spending without cutting social spending: that is the question. By limiting life expectation...

Europe is staggering beneath debt and will stumble and fall into the bottomless pensions black hole. Unless...

There is the Merkel option of creating vassal states...

There is the Obama option of raising the debt ceiling...

The remedy is there and in place. And soon to be in place (Obamacare).

The LCP is dead; long live the LCP...

The Palliativ Portal reports on the outcome of the Review in the UK but says that the LCP should continue to play a primary role in Germany. All current implementation of the LCP can continue.
Palliativ Portal
The University Hospital of Cologne summarizes their reaction to the results in three points: The LCP can and should be first in Germany to be used as is on. All ongoing implementation projects can proceed. The current registration process remains unchanged. In the further development of the essential contents of the LCP, as the communication about dying and the design of the treatment plan, and a comprehensive training program will continue to be the focus. 

Therefore, the basic principles of the LCP will be retained in the further development towards an "end-of-life-care plan."

The Basic principles of the LCP will be retained. The Zentrum für Palliativmedizin is the coordinating body for the LCP and, together with Deutschen Gesellschaft für Palliativmedizin (DGP), will continue to actively promote the application of the LCP in Germany and in international development.

This is Uniklinik Köln – 

Updates to LCP
Here you will find current information from the LCP Coordination Office
Meeting 2014 German-language working group
The German working group on the LCP meets on 03.04.2014 in Heidelberg . All registered facilities will be contacted in due time.
Updates to LCP in England
The concept of the LCP is being fully revised in the Marie Curie Palliative Care Institute Liverpool (MCPCIL). This will have an impact on the further development of the LCP in Germany. In an international meeting on the LCP on 26/11/2013 in Liverpool, where we will participate as coordinator in Germany, these changes are discussed and specified. We will promptly inform about the results and the consequences for the LCP in Germany.
The Review in the UK has passed judgement. Has the LCP had its day? Perhaps not...

The Wirral End of Life Care Plan is only a revamping and re-branding of it.

The Control Record actually says –

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

The international LCP Big Guns are meeting up on the 26th November in Liverpool. Don't think it's all done and dusted, cos it ain't!


The MCPCIL in its October 2013 News Release is as selective as ever in what it reports and what it does not report.

This is MCPCIL
October 2013 MCPCIL Statement in response to the publication of Randomised Control Trial of the LCP-I (LCP-Italy)
This landmark study supports the finding of the Neuberger Review in to the Liverpool Care Pathway that where implemented well the LCP can support the provision of good quality care for dying patients.
It is encouraging that a small improvement is seen in overall care for patients cared for in wards where the LCP is used compared with wards where it is not.

The study reported in Medscape found that the LCP actually offers little clinical benefit.

However, lead author of the study, Dr. Massimo Costantini, stated that the LCP does have the potential to close the gap between hospice care and hospital care.

And in Sage Journals -
Conclusions: These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.Sage Journals' Palliative Medicine
This actually confirms an earlier Study reported here -
Liverpool Care Pathway - A Cover For Euthanasia...?
This also recorded poor effect for symptom control...
In a before-and-after pilot study conducted on 4 hospital wards, the LCP produced improvements on measures of respect, kindness, and dignity, family emotional support, self-efficacy of the family, and coordination of care.
However, it did not improve symptoms of pain, breathlessness, or nausea and vomiting.
The results were published online May 7 in Palliative Medicine.

No worries. They'll get their act together for the LCP Summit in November.

There may be life in the old dog yet.

Saturday, 26 October 2013

Liverpool Care Pathway - Still Wanting It All Ways

A medical holocaust has proceeded, but what do the students know but what they should know...?

The training, the training, the training...

This is from 'The Liverpool care pathway: what students should know' published in Student BMJ

No matter where you are in your medical training, you will most likely have heard of the Liverpool care pathway (LCP), the protocol used in the United Kingdom to facilitate end of life care. After months of bad press the government ordered its review earlier this year. “More Care, Less Pathway,” the review presented by Baroness Neuberger in July, wasn’t entirely negative, accepting that the LCP could “provide a model of good practice for the last days or hours of life for many patients,” and that, “before the widespread introduction of the LCP into hospitals, the care that patients received was variable and there were many examples of poor care.” However, Neuberger said that the application of “generic protocols” such as the LCP to the care of all dying patients is inappropriate, and in the review’s damning conclusion, “it is clear that in the wrong hands, the LCP has been used as an excuse for poor quality care.”

The aim of the pathway was to provide dying patients with a better death wherever they were being cared for. However, no randomised controlled trials were performed to determine what the pathway should consist of, and there was no research carried out after its development to see how it compared with care without the pathway.

Once implemented, doctors and nurses used the LCP for patients who were expected to die within hours or days. First, dying must be diagnosed by a senior doctor—this can be difficult because it is impossible to predict exactly when someone will die.

Being put on the LCP meant a switch in emphasis of care to focus on alleviating bothersome symptoms, which are often similar at the end of life irrespective of the condition from which the patient is dying. 
It is clear that it is not accepted that it is the case that people were inducted onto the LKP who were NOT dying and perished on it.

It is confirmed that no randomised clinical trials were performed in a controlled environment with subjects who have provided consent to participate in them. It is accepted, then, that the whole LCP experience has, in effect, been a clinical trial with subjects who have NOT provided consent to participate in them. Many or most were inducted onto it without prior knowledge and ALL without knowledge of participating in what was, effectively, a clinical trial.

Human clinical experiments are covered by the Nuremburg Code. Permission must be sought. It is not a matter of acting in 'best interests'.

This is Research governance in health and social care: NHS permission for research and development involving NHS patients (second edition)
Information for patients involved in a clinical trial

It is the responsibility of the ethics committee to review the information given to patients recruited into research. This is to ensure that informed consent can be obtained. The NHS does not normally need to consider requiring additional information to the patient.
 The Student BMJ article goes on to quote from a BMJ Editorial –
“[The LCP’s] fate serves to warn us of the dangers of implementing tools that are not properly evidence based,” write Katherine Sleeman and Emily Collis in a recent BMJ editorial. It is a “cautionary tale” they say— if used appropriately, “the LCP can provide a model of good practice for the care of dying patients.” And although the pathway has improved the deaths of some patients, it has also been “the focus of profound grief and regret for others.”

So where does this leave doctors, nurses, and patients? It is not yet clear whether scrapping the pathway will do more harm to patient care than good. “Ultimately, the decision to phase out the LCP was made on the basis of little more than an accumulation of anecdotal evidence,” they continue. “The recommendation by the panel to phase in condition specific guidance over the next six to 12 months should therefore be approached with caution. It is imperative that we do not repeat the same mistakes, and introduce new guidance without first testing it properly.
It is clear that it is still not accepted that the cases which have been reported and, therefore, the countless others not reported contain any reliability of substance and evidence: they are 'anecdotal' just as Earl Howe always claimed them to be!

Nursing Times
There is a "switch in emphasis of care". Anticipatory prescribing is recommended.

The Nursing Times says PRN prescriptions for the four main symptoms are:

Pain - Diamorphine
Nausea and vomiting - Cyclizine
Agitation - Midazolam
Respiratory tract secretions - Hyoscine hydrobromide 


Ah, yes.

Speciality Training Curriculum for Palliative Medicine actually advises that valid consent
is a process that may culminate in, but is not limited to, the completion of a consent form.
and to
Where appropriate, safely prescribe drugs beyond their product licence, or without a product licence, ensuring correct procedures are followed including gaining appropriate patient consent.

Of course, after a shot of midazolam, the patient will pretty much agree to anything...

But that is not permission to participate in a clinical trial.

Further reading -
Liverpool Care Pathway - A Serious Breach Of Trust