Saturday, 1 February 2014

Liverpool Care Pathway - A Good Death Or A Good Life?

The goal should be a good life, through life, to the end of life.

The quality of mercy is not strained.
It droppeth as the gentle rain from heaven
Upon the place beneath. It is twice blessed:
It blesseth him that gives and him that takes.
- Will Shakespeare
The act of mercy does not follow a protocol of instruction; it is not guided thus. Mercy is a well deep within us that springs forth as compassion and concern; it is a cup of kindness that overflows in its abundance.

Thus is the quality of mercy not strained that it will assess the quality of the life and then take that life if its quality is assessed and deemed to be lacking in sufficient quantity; that is a subjective judgement, in any case, and not a basis for a decision of such import and consequence.

The quality of mercy is such that it will assess the quality of that life and seek to improve the lot of that life as well as it may. To do that takes up time and commitment to do so, of course. It is this consideration that motivates those who consider it a mercy to take a life assessed to be lacking in quality; not mercy.

The EoLC Strategy was ALWAYS absorbed by this consideration; by that and only by that - and by its financial impact and consequence.

Ellershaw has observed and commented upon the parallels between America and the UKThese parallels multiply exponentially. The BEACON project may be the springboard for rollout of an EoLC Strategy nationwide.

The BEACON (Best practices for End-of-life And Care for Our Nation’s veterans) trial has been tested and assessed at six Veteran’s Affairs Medical Centers and involved instructing more than one and a half thousand staff in its protocols.

This is Science Newsline -

The multi-component intervention included training hospital staff on how to identify dying patients, how to communicate the prognosis to patients and families, and how to implement best practices of traditionally home-based hospice care in the inpatient setting. The intervention was supported by an electronic order set - called a comfort care order set - and other educational tools to prompt and guide implementation by hospital staff.

"We only die once, and therefore there is only one opportunity to provide excellent care to a patient in the last days of life," writes Bailey and colleagues. "The keys to excellent end-of-life care are recognizing the imminently dying patient, communicating the prognosis, identifying goals of care, and anticipating and palliating symptoms. Since it is not possible to predict with certainty which symptoms will arise, it is prudent to have a flexible plan ready."
Misdiagnosis rates high as a category amongst medical errors...
Medical errors are far from rare, according to several comprehensive studies of the issue. But diagnostic errors – a subset of the overall problem – haven’t received nearly as much attention as other medical errors since the nationwide patient-safety movement began in 1999 with the publication of the landmark Institute of Medicine report, “To Err is Human.”
Medical Malpractice – Medical Misdiagnoses
A patient thus identified and diagnosed as ‘dying’ has their care downsized.

Abandon hope all ye assessed and embarked upon the ferry ‘cross the Styx for the ferryman may not turn around mid-stream!

The Science Newsline article refers to Springer Link -


Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.

To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.

Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.

Six Veterans Affairs Medical Centers (VAMCs).

Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.

Main Measures
Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.

Key Results
Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.

This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.
Trial, implementation, and roll-out. TIR…

What's this? An internationally recognised EoLC Strategy being rolled out globally?

This is UAB News -

A study by researchers at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham says using home-based hospice practices for terminally ill, hospitalized patients could reduce suffering and improve end-of-life care.

The study, published online Jan. 21 in the Journal of General Internal Medicine, is the first to show that palliative care techniques usually used in a home setting can have an impact on end-of-life care for those who die in a hospital.
“More than 75 percent of Americans say they would prefer to die at home, yet only about 25 percent do — the vast majority dying in hospitals or nursing homes,” said Amos Bailey, M.D., director of the Safe Harbor Palliative Care Program at the Birmingham VAMC and professor in the Division of Gerontology, Geriatrics and Palliative Care in the UAB School of Medicine. “This study was designed to see whether home-based hospice practices could be successfully integrated into care in hospitals to improve the end-of-life experience for those who remain hospitalized at time of death.”
The study developed a screening tool for medical professionals to better assess when death was imminent — within a few days or a week.

The multicomponent intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients and families, and implement best practices of traditionally home-based hospice care in the inpatient setting. The intervention was supported by an electronic order set — called a comfort care order set — and other educational tools to prompt and guide implementation.
Tools, interventions and order sets. Their confidence is enforced and underlined with an enthusiasm which undermines reason in their undertaking.

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