Monday, 3 March 2014

Liverpool Care Pathway - "Not Many People Know That..."

Your Life, to the end of your life, in their hands. Are you taking the Michael...?

An article in QLC (Quality of Life Care) discusses Morphine and breathing 

Morphine is one of many drugs that is used to treat moderate to severe pain and also it is used to treat shortness of breath. Not many people know that.
According to Web MDMorphine possesses a high risk for severe, possibly fatal, breathing problems.The risk for breathing problems might also be higher when the medication is initially prescribed and following a dose increase. It is advised to obtain immediate medical help if unusual slow/shallow breathing is observed.

The article, "Morphine and breathing", continues -
In hospice medicine we use it all the time for both and it is one of the standards for the treatment of shortness of breath. If someone is allergic or for whatever reason cannot take morphine, there are other drugs in this same category to try.
There is the thought in the medical community (outside of hospice) that morphine causes respiratory depression and that this phenomenon is always bad. I have a lot of experience with it and I also read what pulmonologists, palliative care researchers, oncologists and other leaders have to say about this too. What I’ve seen over and over again is that it works. It’s amazing what it does for a person’s quality of life. But despite the research and what hospice professionals know, I can’t tell you how many times I’ve heard “…oh no, we can’t treat shortness of breath with morphine, it causes respiratory depression…”
In Hospice, it seems Morphine is, pretty much, viewed as a panacea - even down to getting a quiet night on shift, maybe...?

In the Salmon Observer –
It may be July, but snow is the word that reverberates through Dina Loeb’s head. Her father, Jack Johnson, died in Bastion Place Jan. 12 and Dina and her husband, Bruce, believe his death was, at least in part, a result of “snowing” with the prescription medication Seroquel, or Quetiapine, as it is also known.
Snowing is a colloquial term for sedating an individual so they are no longer intrusive or distracting in their behaviour or the sounds they make.
They “snowed” Jack Johnson, a diagnosed dementia patient, with an anti-psychotic. According to the Alzheimers Society, two thirds of these prescriptions for people diagnosed with dementia are "inappropriate".

Does ‘snowing’ exist and is its use more widespread, in hospital and in hospice, for that quiet night on the night shift?

Do they “snow” Morphine or the 'other drugs in this same category' to get a quiet night on shift? Who's going to know? The patient was in pain. They can tell. They are trained.

According to All Nurses, snowing is being "generous" with the morphine...

These are dangerous people.

This is a Rapid Response patient alert –

This Rapid Response Report alerts all healthcare professionals prescribing, dispensing or administering opioid medicines to the risks of patients receiving unsafe doses.

Every member of the team has a responsibility to check that the intended dose is safe for the individual patient. Knowledge of previous opioid dose is essential for the safe use of these products. There is a wide variety of opioid medicines, and supply shortages may result in products being used which are unfamiliar to practitioners.

The National Reporting and Learning System (NRLS) received reports of five deaths and over 4,200 dose-related patient safety incidents concerning opioid medicines up to June 2008.

This guidance applies to the prescription, dispensation or administration of buprenorphine, diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum, pethidine.

We’re not taking the Michael...

A further Patient Safety alert urges to -
Ensure that naloxone injection, an antidote to opiate-induced respiratory depression, is available in all clinical locations where diamorphine and morphine injections are stored or administered.
Connecting for Health reports on 512 patient harm electronic prescribing errors on "morphine-, methadone- and oxycodone-based medicines which have oral liquid preparations which have been reported as being mis-selected".

Patient harm...

According to the CDC, poisoning is the leading cause of death from injury in 30 states and exceeds motor vehicle traffic deaths.
During the past three decades, the number of drug poisoning deaths increased sixfold from about 6,100 in 1980 to 36,500 in 2008.
During the most recent decade, the number of drug poisoning deaths involving opioid analgesics more than tripled from about 4,000 in 1999 to 14,800 in 2008.

Opioid analgesics were involved in more than 40% of all drug poisoning deaths in 2008, up from about 25% in 1999.
But Peter Saunders - whose defence of the LKP has been truly indefensible and disgraceful - says in Life News that "Morphine kills the pain, not the patient, but some people don't get it".

Trouble is that some people don't get it, and I'm not taking the Michael...

Amazingly, in 2003, to get an RCN 'Certificate of Learning' in Palliative Care as part of your ongoing professional development you just had to read an article on the 'Care of dying patients' in the Nursing Standard 

By reading this article and writing a practice profile, you can gain a certificate of learning. You have up to a year to send in your practice profile. Guidelines on how to write and submit a profile are featured at the end of this article.
Don’t know what Wee Bee Long makes of that. No worse than her own programme of digital learning that wrought so many calamitous outcomes.


Let's see. My dear mum was not one not to speak her mind and her last coherent words to me in this life were that she 'didn't like them in there'.

So, to shut her up, they shoved her in a side room and 'snowed' her into delirium with a chemical cosh of Temazepam, Tramadol and Oramorph (of which we knew nothing at the time and which the HC and the PHSO kept concealed from us).
They permitted my mother to present cyanosed on the Saturday and did nothing. I received a call early on Sunday morning to say she was suffering from heart failure and that they were getting the doctor. Still unaware of the reality of the situation, we thought they were actually getting the doctor at the hospital. No, they were calling Thamesdoc! An hour later, another call revealed that Thamesdoc were unavailable and so they had called an ambulance! Excuse me?

My mother had presented cyanose, been left to deteriorate to a catastrophic life-threatening condition, - and they called Thamesdoc. My mother perished halfway between Caterham Dene and ESH, paramedics ramming tubes down her throat in frantic, vain attempts to revive her. This was reported to me in A & E in explanation of the very apparent bruising. [Letter to Healthcare Commission]

Respiratory depression…

Oxygen saturation decreased –

The first concern is not to save lives. They help them on their way - and they let them go.

This bears marked similarities to our account given here. This is the Gloucestershire Echo 
A SENIOR care home nurse waited over three-and-a-half hours to dial 999 for an unresponsive woman who died just 45 minutes later.
The frail resident from Cheltenham had deteriorated overnight, losing her colour and refusing to eat at the Paternoster Care Home, in Cirencester, on June 4, 2011.
Nurse in charge, Paulina Abiade, was informed that the pensioner was unresponsive at 8.40am, but failed to contact emergency services until 12.15pm.
Instead she called the woman's husband at 10.05am, 10.45am and noon, unaware that he was running errands out of the house.
When an ambulance eventually reached the home, it was too late and the elderly woman died at around 1pm.
And this is Mail Online 

Susan Burgess was just 59 when she died on December 5, 2012 after suffering a pulmonary embolism in her room at Holme House care home in Cleckheaton, West Yorkshire.
Nurse Winifred Jozi was called when Mrs Burgess was found at 6.20am but an inquest heard she refused to attempt resuscitation and didn’t even call for an ambulance - instead, choosing to ring the non-emergency NHS Direct service.

Mrs Burgess’ daughter, Julie Marsden, 40, claims Mrs Jozi - the only nurse on duty - didn’t even check her mother’s pulse, and said she knew there was nothing she could do 'just by looking at her'.
She said: 'I’m absolutely appalled with the actions of nurse Jozi.
'She claimed that she knew my mum was dead just by looking at her, so she didn’t even check her pulse or do any of the other checks that a medical professional should do.
'I’m not a nurse and if someone looked to be in trouble I would do whatever I could to help.
'But this nurse, who claims to have 20 years of experience, just stood back and didn’t even attempt to help.
'She just looked at my mum and said, ‘there’s nothing I can do’. She didn’t even try. She didn’t do her job.'
Nurse Jozi used the Barton Method to quickly determine that there was nothing she could do.

Her 20 years of experience kicked in and she followed the Lakhani Recommendations to treat this poor lady as a 'dignified person' - and let her die.

This is the 21st century. To preserve life is no longer a medical priority.
The inquest heard that Mrs Burgess, of nearby Dewsbury, was last seen alive in her chair at 5.45am. A doctor had ordered she was checked every half an hour due to a suspected water infection.

At 6.20pm staff summoned Mrs Jozi who refused to attempt CPR on Mrs Burgess because it was ‘not beneficial’, the court heard.

Instead she called NHS Direct who told her an operator would call back within two hours.

At Caterham Dene, the anonymous nursing staff stood by and did nothing as my dear mum's life ebbed away. Even as respiratory depression set in, no doctor was summoned. Even as oxygen saturation decreased to perilous levels and presenting cyanosed, no emergency ambulance was summoned. Instead, they called the non-emergency ThamesDoc service which told them they would attend.

This is the 21st century. To preserve the life of one determined to be at the end of their life is not a medical priority.

An hour later and, still, ThamesDoc had not attended. Only then was an ambulance summoned - too late to make a difference...

Further reading -
Liverpool Care Pathway - When The Image Has More Substance Than The Word

Liverpool Care Pathway - And "Shambolic" Doctors

Liverpool Care Pathway - An Act Of Infamy

Liverpool Care Pathway – A Dialogue Of Correspondence

Liverpool Care Pathway - A Negation Of Trust

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