Wednesday, 29 January 2014

Liverpool Care Pathway - Long In The Making...

The best-laid plans are not rushed but mature like an ancient cheese...

They surface surreptitiously, with cunning and with stealth, such that it seems they were always there.

A Review did not prevent the Pathway from claiming another victim...

This is BBC News England –

A coroner has said he is concerned about a lack of formal decision making over the ending of a man's care in the days before his death.
Bob Goold was in intensive care following a fall when food and fluids were stopped at Addenbrooke's Hospital.
He died more than a week after being placed on the Liverpool Care Pathway (LCP), in February 2013.
Coroner William Morris said the authorisation to begin the LCP was a "grey area".
Additional reading -
Liverpool Care Pathway - A Blind Faith

Liverpool Care Pathway - An Italian Perspective And Some Chaff For The Finches
The underlying basis of the DoH EoLC Programme has been the diagnosis of a condition of 'dying'. This is the starting point from which all else proceeds. This is a dangerous arrogance to presume and to suppose...
- The Review
This is a dangerous practice in which they persist for this is what application of the One Percent Rule demands and they are hard at this purpose.

Old-age is already an inescapable and terminal condition. The symptoms of this condition - declining mobility, frailty, absent-mindedness - are signs to watch out for in diagnosis and downsizing care.

A more formal approach was first adopted from the early 1990s. The 1990s saw the development of a proto-pathway at Gosport and the Barton method. This latter would be later co-opted by the GSF as the 'Surprise Question'.

The Wessex Guidelines, published by the Wessex Specialist Palliative Care Unit, was co-authored by Barton [World Medical Times] and practiced at the Gosport War Memorial.

The 1990s also saw the development of a tool - a treatment protocol - which was trialled in hospice then in non-hospice setting and later co-opted by the DoH and rolled out across the NHS - the Liverpool Care Pathway. 

The Peer Review Programme 2004-2007 recommends as good practice adoption of the Wessex Guidelines, roll out of the LCP and implementation of GSF.

The Wessex Guidelines adopt non-verbal pain assessment. According to the Gosport Review, this tool was "inappropriately applied" to rehab patients. However, this is practice to note 'non-vocalised' responses and these would be - and are - interpreted to give 'pain relief'.

A formalisation of approach is recommended in this submission to the BMJ –

This is published 25 June 1994...
Clinicians often decide either to withhold or to withdraw lifesaving treatment in elderly patients. Considerable disagreement exists about the circumstances in which such actions can be defended. Debates about the scarcity of resources in the NHS add urgency to the need to resolve this disagreement. Competent elderly patients have a legal and moral right to decide whether to receive life sustaining treatment. Such treatment should not be withheld or withdrawn on the basis of a patient's age alone. Principles for making decisions about life sustaining treatment in incompetent elderly patients can be defended and should exist as written guidelines.

Clinicians working with elderly patients often face difficult decisions about withholding or withdrawing life sustaining treatment. They must balance the sometimes uncertain benefits of active intervention against the potential burdens. Despite the frequency of such dilemmas little clear guidance exists on the moral and legal status of “non-treatment.”

The lack of such guidance is unsatisfactory for several reasons. Firstly, clinicians often disagree about what is morally and legally required of them. Secondly, this disagreement leads to arbitrary differences in the treatment that elderly patients receive; indeed, on occasion, non- treatment on the basis of old age is used unacceptably as a mechanism for rationing scarce resources. Finally, when disagreements arise within clinical teams or with patients or relatives no agreed policy exists to help to resolve these disagreements.
Informed consent and competence are discussed.
When a clinician has decided that an elderly patient is incompetent to reject potentially life saving treatment no legal means exists for a relative to make a decision on the patient's behalf. The courts have confirmed that only doctors have the right to make such clinical decisions. In doing so, they have a professional duty to act in the best interests of the patient.
And the concept of personhood...
What makes people the same persons that they were as children is that they perceive a narrative chain linking their many memories, goals, and beliefs. If, however, a complete break occurs in this chain, where no connections exist, their personal identity is destroyed. Despite the fact that their bodies are the same these patients are not the same persons that they were. Indeed, without the long term and short term memory to develop new connections they are not persons at all. Even when such patients seem to be doing things intentionally they are primarily reacting to external stimuli.
Responses may not be considered responses but local motor reactions.

The decision not to treat, to withhold treatment, is an act. It is a reasonable position to adopt that such an action that causes or brings about death may be considered manslaughter, potentially murder, in law.

Further reading -
Liverpool Care Pathway – A Loss Of Touch With the Final Reality Of Life
In conclusion, what is the one percent...? 
The One Percent is a 2006 documentary about the growing wealth gap between America's wealthy elite compared to the overall citizenry.
and the One Percent Rule?

It is the growing health gap of curative provision between the UK's elder community compared to the overall population.  

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