Thursday, 9 January 2014

Liverpool Care Pathway - A Golden Opportunity

Bidding for Gold...
and golden research opportunities?

The GSF is leaps and bounds ahead in South Warwickshire. This on the NHS Supply2Health portal –

NHS Arden and South Warwickshire are procuring tenders for a two year contract for provision of a dedicated Practice Development Team to build ‘capacity and capability’ in primary care. This is a pilot scheme to undertake a phased implementation of the GSF across all 36 South Warwickshire Clinical Commissioning Group GP practices, roll out the Route to Success in EoLC in all 29 care homes across South Warwickshire, and facilitate South Warwick GPs in implementing pathways to support future proofing of these QOF QP outcomes. This is an open bidding process on the Arden commissioning e-portal. Opening bids, please, for this lucrative £220 grand project. Submit by 24th January.
Care type:
Prevention and education; Part of a Care Pathway
Care Pathway – yep, it’s for an EoLC Pathway.
Education - hmmmm...
Prevention - ?????????

BBC News Scotland reports the LCP is to be phased out in Scotland -
A controversial system of caring for dying patients is to be phased out in Scotland, it has been confirmed.
The Liverpool Care Pathway (LCP) can involve withdrawing medication, food and fluids to patients in the final days and hours of their life.
review of the pathway in England earlier this year found it had sometimes been "misused" by the NHS.
The Scottish government said new guidelines would be given to health boards next year.

This is the finding of the Living and Dying Well National Advisory Group –
The group recognised that used correctly, the Liverpool Care Pathway has supported good quality care in the last days and hours of life in Scotland. However, it also recognised that the inappropriate use of the Liverpool Care Pathway may, on occasion, inhibit the provision of high quality care. It is essential that action is taken to address these potential concerns and to provide clear guidance for staff on good practice in supporting people in the last days and hours of life.
The Scottish Government has accepted the National Advisory Group recommendations that the Liverpool Care Pathway should be phased out in Scotland over the next 12 months.
There are concerns that "inappropriate" use of the LCP may have had undesired outcomes and it is "essential" that action is taken to address these concerns.

It is impossible to determine now how many poor souls were "inappropriately" placed on the pathway or suffered through its "inappropriate" use; the evidence has been disposed of.

The SPPC (Scottish NCPC) and Marie Curie are holding a seminar on 5th February at the Scottish Parliament to mull over the Scottish EoLC Strategy and to celebrate its 5th anniversary. Audience participation is encouraged. Places are limited. Apply to Richard Meade at Marie Curie by Friday 10th!

NHS Scotland has issued Interim Guidance for EoLC which is little more than a 'pull your socks up' LCP -

The document
  • warns staff to take into account "the uncertainty involved in identifying if someone is dying".
  • urges staff to understand the "importance of sensitive and clear communication with patients and families".
  • reiterates the role of hydration nutrition and mouthcare.
The More Care Less Pathway Review has hit home -
Sensitive communication must take place with the patient (where possible), family, any welfare attorney and those close to the patient. This communication should include the patient’s condition, expectations relating to how their condition is likely to change, the wishes of the patient and their family including preferred place of death, and agreed goals for the care that will be provided. This communication must acknowledge any uncertainties that may be involved in predicting what is likely to happen and should reassure families that regular review will form a core part of the care provided. 
Agreement that a patient’s death is expected within hours to days must be based on a multi-disciplinary discussion about the patient’s condition which recognises that diagnosing dying involves an element of uncertainty. Responsibility for decisions reached is carried by the senior clinician responsible for the care of the patient.

There is recognition that a grooming process must proceed and should take note that reassurance that the pathway does have turnings should be given.

Making this diagnosis will result in not continuing any medical interventions that are inappropriate.
The focus of care will shift towards interventions that keep the patient comfortable. Identifying that a patient may be in the last days to hours of life also allows the team to focus on any preferred place of death.
 So, while
It is also essential that all members of the team recognise that diagnosing dying involves an element of uncertainty, so regular ongoing monitoring of a patient’s changing condition and needs should continue.
 The patient will be whisked off home (residential or nursing) so the MDT that consigned them on the pathway won't be around to review that anyway.

The Foreword questions the issuing of plans
Reviews of the use of the Liverpool Care Pathway has underlined the fact that it has increasingly being recognised that issuing plans and guidance is not always sufficient to ensure that everyone receives the same high quality of care.
But, nevertheless, recommends making a management plan adhering to specific and recommended guidelines
A plan for managing the patient’s condition should be made. This should include a record of decisions made by the multi-disciplinary team, including explanation of reasons for a diagnosis of dying, and any decisions to stop or not begin medical interventions which are considered to be of no benefit to the patient.

which amounts to the same thing.

It is surprising that the document recommends that
The outcome of any ward round or multi-disciplinary discussion should be clearly documented in the case record.

It is surprising in this respect, that this needs to be mentioned. Isn’t this something that is done as a matter of course...?

Great attention is paid in the document that consideration should be given to the patient’s psychological, spiritual and social needs and recognition that these impact upon the patient. Also that

Patients who are dying must be cared for with respect and dignity
Only when the patient is diagnosed as ‘dying’ are these recommendations made? What of those patients diagnosed as living...?

Further reading -
Liverpool Care Pathway - An Awayday On The BMJ... particular, the comments of Drs Tessa Richards and Philip Harrison.

In summary, there are three recommendations -
1. Nutrition and hydration in the last days and hours of life
2. Recognising the uncertainty of a diagnosis of dying
3. Communication with patients and families and between staff
And various addendums to adhere to, such as the national DNACPR Policy.

The EoLC document also references the  Incapacity (Scotland) Act 2000: Code of Practice –

With various provisos,
Research on adults incapable of consenting is authorised under the Act...
4.2 One of the overriding conditions attached to involving adults with incapacity in research is that similar research cannot be done by involving adults who can consent. This condition is paramount. It is not sufficient to say there are no capable volunteers.
Even so, “minimal” risk or discomfort is acceptable and
Where no direct benefit to the adult exists
4.5 The first of the conditions set out above is that the research must be of real and direct benefit to the adult involved. However, subsection 51(4) of the Act provides exceptionally for the possibility that research may be carried out even where it is not likely to produce real and direct benefit to the adult. This is where the research is likely to improve the scientific understanding of the adult's condition and in the long term contribute to the attainment of real and direct benefit to persons suffering from the same form of incapacity.
Furthermore, in the circumstance of “Emergency” research,
Subject to the trial having been approved by an ethics committee such "emergency" research can proceed without ethics committee approval and without the consent of any guardian or welfare attorney, or the adult's nearest relative, if :-
(i) it has not been practicable to contact any such person before the decision to enter the adult as a subject of the clinical trial is made, and
(ii) consent has been obtained from a person, other than a person connected with the conduct of the trial, who is:-
(a) the practitioner responsible for the medical treatment provided to the adult, or
(b) a person nominated by the relevant health care provider.

NHS England is enacting policies of 'presumed consent' in their Business Plan -

We will act as a facilitator of research – for example, we are planning to investigate a system of ‘presumed consent’ to take part in research studies for all patients treated in teaching hospitals.
NHS England Business Plan
The ball is rolling...

Further reading -
Liverpool Care Pathway - A Cost Efficiency

Liverpool Care Pathway - A Negation Of Trust

Liverpool Care Pathway - Still Wanting It All Ways

Liverpool care Pathway – A Moral Minefield

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