Tuesday, 25 February 2014

Liverpool Care Pathway - Somewhere... Is There Erewhon?

Once that first step is taken, the next - and each successive step - becomes easier...

Somewhere, on a distant island off a far-off continent…A man, trained to protect and serve life, recalls and regrets how his moral perspective was turned to serve killing and death executed in the name of medical research, consent presumed and uninformed.

This is Japan Times –
Donning the crisp, Imperial Japanese Army khakis gave Ken Yuasa a sense of power, as a superior being on a mission to liberate China from Western colonialism.
“The uniform made me feel incredibly sharp.  Once I put it on, I was convinced Japan would triumph,” recalled the wartime surgeon, who was deployed to Changzhi (then Luan) in Shanxi Province in February 1942.
“I was in denial of the things I did in Luan until the war was over. It was because I had no sense of remorse while I was doing it,” Yuasa, 90, told The Japan Times in a recent interview.
“The atmosphere in which we cannot freely express our opinions and challenge government orders is eerily similar to that of my time. And back then, before we knew it, we were heading into a wrongful war,” the doctor warned.
They donned their white coats and willingly participated in what was clearly a trial as the LCP and, then, its legal version 12 was rolled out in the EoLC program which followed.

Confident in their arrogance, they do not question the roll-out of a Strategy to limit life through a policy of downsizing care. How may they when the nuance of language is subtly altered such that the withdrawal of care becomes 'care'.

The economic urgency to rationalise care distorts their moral perspective such that they are able to convince themselves and others of the correctness of what they do. Their literature - quoted in these pages - ever references the dire ecomomic projections of the demographics that threaten the continued viabilty of healthcare.

Zeke's Complete Lives system is coming into its own. Such is their zeal, they are moving the goalposts for escalation of treatment across the board.

Somewhere, on a distant island off a far-off continent…

This is the Japanese Finance Minister reported on Time Newsfeed 

Taro Aso, who also serves as the deputy prime minister, had been in office little more than a month when he insulted Japan’s elderly on Monday, calling those who can no longer feed themselves ”tube people,” and claiming that treatment for just one patient close to death can cost the government “tens of millions of yen” a month.
In a country where the elderly are shown the highest deference and respect, Aso’s comments go particularly against the grain. People over 60 make up more than a quarter of Japan’s population, making it especially surprising that a senior politician would speak out so bluntly.
Japan’s aging population does cost the country’s strained social services, and the number of elderly people is only expected to increase. In just 20 years, projections suggest that seniors will outnumber children 15 and younger by nearly 4 to 1. According to the Organization for Economic Cooperation and Development, Japan’s at-birth life expectancy is 83, one of the highest in the world. That imbalance means the ever-shrinking segment of people of working age will be burdened with the cost of paying to take care of their grandparents and great-grandparents.
Mr. Patrick Gordon Walker’s landmark observations echo down the years and, somewhere, on a distant island off a far-off continent…

This is the Guardian 
Jeremy Hunt's recent visit to Japan passed almost unnoticed in Britain. Yet the issues he discussed with Shinzo Abe, the Japanese prime minister, and the health minister, Norihisa Tamura, touched on a problem that is likely to dominate social policy in the next decade:dementia care. One in four of the Japanese population is over 65. By 2050, the proportion will be 40%. There are already 4.6 million people with dementia in Japan. Britain, with 10 million people over 65, has 800,000 people living with dementia, at an annual direct cost to the Treasury of more than £10.2bn pounds. By 2050, Britain is expected to have around 1.7 million dementia sufferers.
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 NHS operates a policy of non-exclusion. To ensure that no-one shall be excluded from this 'presumed consent' system, hospitals are being given 'university hospital' status.
university hospital is an institution which combines the services of a hospital with the education of medical students and with medical research. These hospitals are typically affiliated with a medical school or university.
- Wikipedia
Policies of 'presumed consent' are being echoed across the pond…

This is the New England Journal of Medicine 
"...in a learning health care system with ethically robust oversight policies, a streamlined consent process could replace formal written informed-consent procedures for many studies, and patient consent would not be required at all for some trials."

An NHS Scotland EoLC document 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, where there is “minimal” risk or discomfort this still is acceptable.

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.
Further pertinent reading -
Liverpool Care Pathway - A Golden Opportunity

One step at a time and the next becomes easier and, when it is down a slippery slope we tread, each step becomes a rush toward the next.

The Social Architects are hard at their Labours.

Additional reading -

Liverpool Care Pathway - It Cast Its Shadow Long

Liverpool Care Pathway - Nice One!

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