Tuesday, 5 November 2013

Liverpool Care Pathway - As If We Didn't Know

Are these quality decisions that determine 'quality' and 'futility' of life?

When care is downsized, the glass is seen half empty, lives are in danger, deemed not worth saving. When cost-saving steps into the picture, all moral restraint is removed.

This is allacademic -
1. Catenacci, Michael., Saussy, Jullette. and Hill, Eric. "Estimated Cost-Savings of a Pre-Hospital Traumatic Arrest Do-Not-Resuscitate Protocol" Paper presented at the annual meeting of the National Association of EMS Physicians, Registry Resort, Naples, FL<Not Available>. 2013-11-03 <http://citation.allacademic.com/meta/p55914_index.html>
Publication Type: Abstract
Abstract: OBJECTIVES: Surviving traumatic pre-hospital cardiopulmonary arrest(TPA) is a rare event. Futile resuscitations contribute to increased healthcare costs and put medical personnel at risk. Previous research has shown that TPA and initial cardiac electrical activity <40 bpm is prognostic in identifying those patients that cannot be revived. Many EMS systems have implemented TPA termination of resuscitation protocols. We hypothesized there would be significant cost-savings associated with implementation of a new TPA ‘Do Not Resuscitate’(DNR) protocol in our region. METHODS: A new TPA DNR protocol was put into place by the Orleans Parish Medical Society on June 1, 2003 that allowed issuance of a DNR order for adult patients(≥18 years) that were pulseless, apneic and had a initial cardiac rhythm of asystole or PEA less than 40 bpm. Data was collected on victims of TPA over a 14 month period from August 1, 2003 to September 30, 2004. All TPA patients that were resuscitated were prospectively followed and cost of hospitalization and measures of survival were recorded. Additionally, all TPA DNR orders with patient demographics were recorded by an online medical control physician in a centralized file. RESULTS: Over the 14 month study period, there were a total of 75 patients that suffered TPA that were resuscitated. The total cost of resuscitation for these patients was $465,270.36 with a mean cost of $6083.60(95% CI $1960.42-$10,206.79) per resuscitated patient. Nine patients(12%) survived to hospital admission, the average length of hospitalization was 3.0 days(95% CI 0.69-5.31), and there were no survivors to hospital discharge. There were 132 DNR orders recorded, 25 of which were excluded from analysis due to missing field data(eg initial cardiac rhythm). Estimated cost-savings was calculated as $650,945.71 (107 patients x $6083.60 per patient). CONCLUSIONS: Traumatic pre-hospital arrest protocols that allow issuance of ‘Do-Not-Resuscitate Orders’ for medically futile cases result in substantial estimated cost-savings. This cost-savings may have been underestimated in our study due to exclusion of 25 DNR orders secondary to missing data.

Of course. As if we didn't know...

A TPA DNR protocol was established. Effectively, an experimental trial on non-voluntary patients was commenced that denied those deemed 'futile' the chance, the opportunity - however slim - of life.

When budgetary constraint stands shotgun on the ward and steps out into the community, this moral peril brings us all to the brink of the precipice.

This is Commissioning End of Life Care, a document jointly written by the National Council for Palliative Care and the DoH National End of Life Care Programme –

The next two years provide a unique opportunity for new commissioning organisations to position themselves in the best clinical and financial position before they begin business as legal entities, for some at least as early as April 2013. 

By targeting end of life care, emergent commissioners can place themselves in a strong position for one of the major required areas of improving quality and safety of care; improving patient and carer experience and making care more cost/resource efficient. 

Tackling end of life care early can offer a number of significant ‘quick wins’ in improving the quality of care in your locality. People should be supported to be cared for and to die in their preferred place of care, which is usually their home (End of Life Care Strategy 2008). It may also include other community based settings such as a care home or sheltered housing. This means commissioners should ensure there is planned 24/7 provision of community support, including care co-ordination, nursing and symptom control. 
End of life care accounts for a high proportion of NHS spending. The Demos think tank has estimated it as at least a fifth of NHS costs and a total of about £20 billion 

There is considerable scope for improvement using interventions such as early identification triggers, advance care planning, co-ordination of care and effective multi disciplinary team (MDT) working.
There are a number of "significant 'quick wins'" to be made. EoLC costs £20 billion...
Additional reading –
Liverpool Care Pathway - A Data Bonanza
Liverpool Care Pathway - The Micawber Principle

These are assessments of 'quality' and 'futility' of life.
This is a post on a MND Association Forum -

           25th October 2013, 13:13

        not what i wanted to hear.
hi peeps, i had a conversation with my gp this week, about a do not resuscitate form. i am a bit miffed at the way it was put across, as though it wouldnt be fair on everyone else if was brought back and my feelings dont matter as much. i know i have to take others into account, but i am only 32 and even though ive had mnd for 4yrs i am mostly enjoying my life. i am still able to enjoy watching my kids grow up, who i love with all my heart. i have a great wife and family. i am just not ready to give that up yet no matter what, i will enjoy my life whatever it throws my way. am i being selfish,  just after the thoughts of others and honesty is welcome. thanks  mik
And this is a familiar tale...

Repeat prescription medication either not administered or withdrawn; a complaints process designed to grind you down, send you home and make you want to give up...
This is the Blackpool Gazette -

Ms Robles' father Reginald Iliffe was admitted to Alexandra Hospital in Redditch, Worcestershire, with problems swallowing, three days after being diagnosed with cancer.
The great-grandfather, who had worked for the NHS all his life as a dental technician, died of a heart attack nine days after he was admitted in April 2005, despite the fact that his cancer specialists had said they expected him to live for 18 months.
His family later learned that during his stay he had not been administered any of his heart medication - which he had been taking for more than 20 years.
Because Mr Iliffe had been admitted with a lump on his oesophagus, his medical notes indicated that he was "nil by mouth", so his oral medication was not administered, Ms Robles said.
His daughter said that because no-one bothered to change Mr Iliffe's medical notes so his medication was delivered intravenously, he did not receive any of the crucial drugs.
The family pursued a complaint that ran them through the wringer of the Healthcare Commission and the PHSO. Eight years later, it took a solicitor to wring an apology out of them.

Complaints are not new to the Alexandra. BBC News reported Jeremy Hunt to be "disgusted and appalled" at the accounts of neglect there.

'Learnings' are taken, of course, but they are never learned. And why should they be when deaths are but "shortcomings" and a life, on average, is worth a paltry £10 grand?

This is the Mail Online reporting in January 2012 –
Early this month Mr Cameron announced that nurses would have to undertake hourly ward rounds to check whether patients are hungry or thirsty, need help going to the lavatory or are in pain or discomfort. 
And last year similar guidance was issued by the General Medical Council reminding doctors that care does not begin and end with clinical treatment. 
Reports by the Care Quality Commission, the Health Service Ombudsman and the Patients Association have all highlighted poor care. In October, a review by the CQC watchdog found that half of 100 hospitals visited by its inspectors were not doing enough to ensure elderly patients had enough to eat or drink. 
In Alexandra Hospital in Redditch, Worcestershire, doctors had resorted to prescribing patients with drinking water to ensure nurses did not forget.

This is the Mail Online reporting in August 2013, a year and a half later –
The family of Sandra Aston, 79, have told how they smuggled ice lollies in to Redditch Alexandra Hospital after nurses left her so thirsty her lips cracked and bled.
Mrs Aston was ‘treated like an animal’ by nurses, who claimed they could not help when her family begged them to act as she became increasingly dehydrated.
While she was too weak to drink from a cup, her thirst could have been quenched with oral sponges. But staff did not provide these, leaving her family to feed her ice lollies they bought outside.
...Redditch Alexandra Hospital.

Compaints, complaints...

The Government issued a press release last week which has proposed a 'revolution' in the way complaints are handled -

This discusses the history and determining factors behind the commissioning of a report from Ann Clwyd into the gruelling NHS complaints process and the prejudiced and biased and dismissive attitudes of the various regulatory bodies.

The press release includes contributory comments from Ann Clwyd, Jeremy Hunt, and Tricia Hart. Has Ann Clwyd succeeded? Will her proposals succeed?

The problem of communication is raised. A Nudge in the right direction is proposed:
Patients should be helped to understand their care and treatment. While written information is helpful, it is always important to discuss diagnoses, treatments and care with a patient. Patients frequently need to revisit topics already addressed. Where appropriate, their relatives, friends or carers may be included in discussions.
A bit of friendly advice from someone on the receiving end...

With the appropriate preemptive grooming, all issues may be stopped in their tracks before they brew into an intractable problem. Remember: If it may be circumvented, it may be prevented!

This is The Telegraph on the subject of that report -

NHS complaints review 'will be rendered useless’ 
The NHS is braced for fresh criticism about the way it handles complaints from patients as safety campaigners accuse the Government of “legitimising cover-ups” by deciding to limit a new proposed legal duty of candour.

The Mail Online reported -

Hospitals must investigate allegations of medical blunders – even if it exposes them to the threat of legal action.
Health Secretary Jeremy Hunt said the NHS was obliged to respond to all patient complaints of poor care.
The guidance came as it emerged some hospitals have refused to investigate concerns or halted inquiries, even if the aggrieved parties only sought legal advice.

It has 'come to light'...?

The first thing we were asked at the Healthcare Commission stage and the PHSO stage was were we considering legal action. The implication was plain that if we were the complaint could not proceed.

A similar implication was made by the N&MC. 

Will there be a legal Duty of Candour (Robbie's Law)?

Earl Howe, who infamously dismissed the reports on the Death Pathway as being 'anecdotal', now comments in the Lords that any duty of candour would be limited to cases resulting in death or serious injury. This is counter to the recommendations made by Robert Francis QC in his Final Report on the Mid Staffs scandal.

There will also be another parameter of limitation or plausable denial...

The Worcester News reported in January 2012, long before the flawed Review into the LKP was mooted by Norman Lamb -
A county MP is determined that a care pathway for the dying does not become “euthanasia by the back door”.
West Worcestershire MP Harriett Baldwin has welcomed new guidance in the county’s NHS acute team to improve a care programme for terminally ill patients. 
She first learned about the pathway three years ago when it was mentioned in the medical notes of a woman who had died at Worcestershire Royal Hospital in Worcester with dehydration. 
Mrs Baldwin was in contact with the woman’s niece and contacted the hospital trust for answers. 
When the damning report into care at two wards at the Alex by the CQC was published, Mrs Baldwin was concerned that this was linked to interpretations of the Liverpool Care Pathway. 
She said: “It’s important the hospital has the right training process and safeguards because I would hate to see any suspicion that it was euthanasia by the back door.” 
Mrs Baldwin requested the Liverpool Care Pathway be considered as part of the acute trust’s review of the failings identified by the CQC report. 
Mrs Baldwin has raised concerns with trust management on several occasions about the use of the LCP after hearing from constituents. 
She said: “I have been urging the acute trust to take another look at the way it uses the Liverpool Care Pathway for some time and I am pleased that these steps have been taken. 
“It can of course be difficult to define the moment when a patient becomes terminally ill and it can be upsetting if all relatives see is that nutrition and hydration are no longer being given.”

It IS of course difficult to define the moment when a patient who is not diagnosed with a terminal illness is terminally ill. It IS upsetting to see nutrition and hydration withdrawn.

Nurses, reportedly, said they ‘could not help’ when family begged them to act as Mrs Aston became increasingly dehydrated...


How many deaths from dehydration were LCP related? The GLA Conservative report demonstrated that Trusts just do not have, or have conveniently ‘lost’, the records.

The Worcester News report continues -
Jenny Garside, end-of-life care facilitator for Worcestershire Acute Hospitals NHS Trust, said the trust had been participating in the Liverpool Care Pathway for a number of years and the latest – version 12 – was now being used in the county’s three acute hospitals.
She said: “The updated pathway contains a detachable leaflet for relatives and friends about the use of the LCP and issues such as hydration and nutrition that are often a major concern during the end-of-life phase for patients.
“The new pathway also gives clearer guidance to medical and nursing teams about identifying and placing a patient on the LCP, multi-disciplinary team (MDT) review and issues such as hydration and nutrition.
“The trust has two end-of-life care facilitators – one based at Worcestershire Royal Hospital and the other at the Alexandra Hospital, Redditch.
“They visit all ward areas to arrange training on the new document and offer advice and support. Staff can also access an online e-learning package.
The trust takes part in the Marie Curie National Care of the Dying Audit to benchmark the use of the document in the trust against a national standard. The training in the trust is then tailored to identified areas of need.
The e-learning package will be the shameful Bee Wee package reported in these pages. Dr. Bee Wee is pictured in a Macmillan Newslettter having 'fun' at a promotional photoshoot...
Liverpool Care Pathway - The Sneak In The Waiting Room

Liverpool Care Pathway - An Arrogance Of Infallibility And Denial Of Error

The Audit mentioned was selective and not comprehensive.

A medical holocaust has proceeded. A Programme to Limit Life is ongoing.

Further reading -
Liverpool Care Pathway – "So This Is Christmas..."

Liverpool Care Pathway - A Failure Of Care

Liverpool Care Pathway - They Do Not Have The Paperwork

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