Sunday, 6 April 2014

Liverpool Care Pathway - The King Lives!

The King has not left the building. He has been seen on the way to and from the theatre.

This is the Chief Executive’s Report of the Guys and St. Thomas’ Board of Directors Meeting –
The Trust Management Executive recently approved new ‘Principles of Care for Dying Patients’ adapted and developed by Guy’s and St Thomas’ from the ‘Kingston Hospital tool’ in response to the recommendations made following the review of the Liverpool Care Pathway – More Care, Less Pathway (Neuberger July 2013) recommending the withdrawal of the Liverpool Care Pathway within 6 – 12 months. Following the implementation of this new approach the Liverpool Care Pathway has been withdrawn from clinical practice from January 2014.
So they’re not using the LCP anymore. Ho, ho... Just take a look at these tweets on Twitter - 
"Our survey found many trusts are not on course to scrap the Liverpool Care Pathway by the summer deadline. This change was not handled well"
"At 1 trust "heated discussions" with relatives concerned their loved one ws being killed led to big drop in use of LCP But what replaced it?" 
JustMe ‏@princessandtoad: "end of life care pathway" 
Janet Snell ‏@Janet_Snell: "Is that what's known as rebranding?!" 
JustMe ‏@princessandtoad: "pretty much. It's silly and a waste of money to be honest." 
Janet Snell ‏@Janet_Snell: "princessandtoad Guys has replaced LCP using Kingston trust idea: Principles of Care for Dying Patients A CNS reviews all cases within 48hrs"
Janet Snell @Janet_Snell is "Acting deputy editor of Nursing Standard but tweeting in my capacity as me".

And here is Nursing Standard –

Janet  put it on Twitter.

Janet put it in the Standard.

"Most acute hospitals are still using the Liverpool Care Pathway."

They're just not calling it that exactly.

So, what’s the ‘Kingston Trust idea’? The Kingston Trust ACP Clinical Audit shows -
Cycle 1:
•          Retrospective case notes analysis of the last 40 patients on the Kingston Hospital Palliative Care Register on a single Care-of-the-Elderly ward.
•          We audited five key areas: resuscitation status, prognosis, ceiling of care, re-admission plans and patient/family awareness. Our focus was whether there was a documented discussion regarding each of these rather than the outcome of the decision.
•         In addition, discharge summaries were reviewed to see whether this information had been communicated to the patient’s GP. 
Implementation of change:
     •          We introduced an ACP Summary proforma where outcome from discussions around the above five key areas could be summarised in one place.
•          On call teams had to make escalations plans for 4 patients.
•         The proforma was introduced at a local Care-of-the-Elderly department meeting and teaching sessions were held for junior doctors.

Cycle 2:
    •         The medical notes and discharge summaries of 40 further patients were audited prospectively for the subsequent forty patients on the register.
•          Patients who had died supported by the Liverpool Care Pathway (LCP) had excellent documentation. 100% of these patients were not for resuscitation, 100% had a ceiling of care documented and 94% of their relatives were kept informed. In general, documentation for these patients was clear and easily accessible.
Cycle 1:
•          Documentation regarding prognosis and ceiling of care (escalation plans) was very poor; often it was very difficult to find in the medical notes which would pose a huge problem if an on call team was called to see the patient acutely.
•          On call teams had to make escalations plans for 4 patients.
•         Despite 77% of patients and their relatives having documented discussions regarding diagnosis and prognosis, we found that this was often not communicated in a timely fashion. For instance, one family made a formal complaint that they were not aware of their relative’s prognosis until she was in her final stages of life and another was informed of diagnosis/prognosis only on starting the LCP even though this patient had been unwell in hospital for several weeks. 
Cycle 2:
•         The re-audit results following the implementation of the ACP Summary showed an improvement in all 5 key areas.  The target was not met for prognosis, likely due to the fact that prognosis is often uncertain and difficult to estimate.
•          In 3 cases, conclusive decisions about future hospital management were not possible. Importantly, all of these discussions were communicated in the discharge summaries so further discussions could be initiated in the community. No escalation plans had to be made by on call teams.
This is Newspeak:
Patients who had died supported by the Liverpool Care Pathway (LCP) had excellent documentation - They have an enthusiasm that is ruthlessly and determinedly thorough in ensuring the patients reach their final destination in one piece.
100% of these patients were not for resuscitation - They all had a DNR slapped in their notes.
100% had a ceiling of care documented - All curative care was a no-no!
94% of their relatives were kept informed - They had been convinced (groomed) that the patient had an untreatable and terminal condition... thereby causing a great deal of harm in itself and ensuring a self-fulfilling prophesy. 
In general, documentation for these patients was clear and easily accessible - The grooming was thorough so they had nothing to hide.
The Kingston ACP

With implementation of the ACP Summary there was an improvement in all 5 key areas.

The target was not met for prognosis, “likely due to the fact that prognosis is often uncertain and difficult to estimate”. Prognostic error translates into diagnostic error...

and excess deaths.

At Guy's and St. Thomas', they are proud of their record of identifying patients for palliative care. This is the home of Amber.

Excess deaths...?

There have been alarming reports of narrow escapes from the clutches of these fanatical followers of the death cult which struts through hospital ward and into surgery consulting room.

Further reading -
Liverpool Care Pathway - A Right Carry On Up The Pathway 
Liverpool Care Pathway - In The Best Interests Of The Interested
Such is the arrogance of the arrogant –

The scope of your focus will always direct the decision-making process and determine outcomes. At Guy’s even Amber has so successfully directed that focus that a report showing that the percentage of patients recorded as ‘palliative’ has increased from 1 per cent in 2008 to 32 per cent in 2012 has sent alarm bells ringing in an independent auditor’s ears to raise the alarm at Westminster.

Under the umbrella of the ruthless logic of a programme rolled out by the State and you have death on a production line.

Such is the arrogance of the arrogant –

Amongst papers submitted at the 10th Palliative Care Congress, 12th–14th March 2014, was:

This found that 25% of those surveyed (50% of those who responded) actually want the LCP as part of mandatory training.

This found that nearly a third of those surveyed (57% of those who responded) consider the LCP should only be used in the final 48 hours of life. They will use the Barton Method to determine this!

This found that those who refuse to accept the limits of their fallibility are doomed to repeat the errors of their hubris.

30 sets of LCP case notes were analysed using the NCDAH proforma template to examine compliance against the recommendations - That Marie Curie NCDA, it will remembered, sanctioned use of selected data sets to permit best outcomes being used (Shout Fix?).
Results were compared with last year's audit.
4 hourly assessments carried out by staff had increased by 1% - And what was checked?
Discussions around spirituality had increased by 9% - Talking... It's so important:
"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely - and he came in and he was sort of asking us if we'd thought about the funeral and how we were going to tell our daughters, and just, sort of, getting us to talk about it, I suppose."
- Kathleen Vine's granddaughters
Medication prescribed on a prn basis had increased by 9% - All adds up to fullfillment of a self-fulfilling prophesy.

 The King has been given CPR and is in good voice.

Additional reading -
Liverpool Care Pathway - The Early Years

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