Tuesday, 1 April 2014

Liverpool Care Pathway - The Werther Defectives

When the dots join up, do they not forge a link in a chain?

Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT)

The basis for the Wessex Guidelines and the Barton trials at Gosport which led to the development of the Liverpool Care Pathway, the EoLC Strategy and the Life Limitation Programme...?

This is Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT) -
Demerol (meperidine, an opiod) is a narcotic pain medicine used to treat moderate to severe pain.
Phenergan tablets and elixir contain the active ingredient promethazine, which is a type of medicine called a sedating antihistamine.
Chlorpromazine, a neuroleptic, (as chlorpromazine hydrochloride, abbreviated CPZ is marketed in the United States as Thorazine and elsewhereas Largactil or Megaphen.
Here, Fox News reports on possible links to Demerol in the death of Michael Jackson...
“Demerol has a tremendous amount of side effects,” Dr. Patrick Annello, an anesthesiologist and pain management specialist at St. Francis Hospital on Long Island told FOXNews.com. “It can cause rapid heart rate, arrhythmias — and given in high enough doses — it can cause respiratory depression or shallow breathing.”

If he took other medications that are sedating – which pain medications usually are – in conjunction with Demerol, it can definitely cause shallow breathing and decreased oxygen levels, ultimately leading to respiratory arrest or heart attack, Anello said.
Amongst the mix of drugs that eventually took out the 'King of Pop', was there a lytic cocktail?

It is the combination of drugs - a neuroleptic, an opiod and an antihistamine - injected intravenously, that forms an apparent connecting link, from cocktail, to concoction, to the clinical protocol of treatment that is the Liverpool Care Pathway.

A 1999 Pub Med article cautioned in regard to the administration of diazepines, in particular Midazolam, and recommended monitoring of respiration.

The lytic protocol has been likened to euthanasia...

Euthanasia: Ethical and human aspects

By Council of Europe

 In 1980 the Association for the Right to Die with Dignity (ADMD) was set up in France (branches were created in Spain in 1984 and in Italy in 1986). Article 1 of its statute states that the association’s aim is “to promote the legal and social right to have control over one’s body and one’s life in an independent, responsible manner [and] to choose freely how to terminate one’s life so as to live it to the very end in the best possible manner” (Pohier, 1998). All the Associations campaign for three things: the right not to suffer, the right to refuse unwanted life-prolonging treatment, and the right to voluntary euthanasia at the patient’s request.
In the 1980’s and 1990’s, alongside these developments, the practice of illegal euthanasia was spreading. Death was caused by lytic cocktail or DLP, a combination of Dolosal, Largactyk and Phenergan, administered by intravenous injection, or by potassium injections. Certain doctors were to become specialists in the practice of euthanasia (or assisted suicide) at their patient’s request. The best-known were Doctors Julius Hacketal in Germany, Peter Admiraal in the Netherlands, Jack Kevorkian in the United States and Léon Schwarzenberg in France.
This is -

Suffering and Dignity in the Twilight of Life
edited by B. Ars, Etienne Montero

For several years now, the results of opinion polls on euthanasia have been the same. Eighty percent of the population is in favour of euthanasia, which does not surprise me when, basically, the question asked comes down to the following dilemna: would you rather die quickly and without suffering, or in great suffering and inundated with tubes?
Misinformation, because we consciously omit to tell future patients that the physician does not have the right to persecute them, that they are legally in control of the decisions that concern them, and  that we are no longer ill-equipped to deal with pain.
Misinformation, because we are careful not to say out loud what health care professionals are perfectly aware of: that the opinion of a healthy person, and the opinion of someone who is ill, are two completely different things.
This is the die loaded, the question phrased in such a manner to produce a particular response.
Nearly all lytic cocktails are administered to patients without their knowledge, or even against their explicitly expressed desire.
This is the policy that followed through into the Barton trials at Gosport, up to the illegal Version 11 Liverpool Care Pathway - and beyond.

Physicians may choose to administer lytic cocktails if they perceive incurable disease as failure, if they do not dare tell the patient the prognosis, if they cannot accept their limitations and powerlessness. Nurses can have the same feeling, in addition to the suffering they must endure every time there is a profound difference of opinion between the curative medical care and the patient’s actual condition, every time they cannot get the necessary analgesics, every time the family turns to them because there is no dialogue with the physicians, every time the doctors desert the dying person’s room and leave the nurses to take all the responsibility.
And so, by doing away with the patient, the health care professionals get rid of the source of their disturbance. Or, sometimes, and far more cynically, it’s to manage the available beds!

This is the policy that persists to this day. It's all about the money...
Typically towards the end of life, each unplanned admission to hospital costs more than £3,000. In the last 12 months before death, patients average 3.5 admissions each, with estimates that at any one time 20% of all hospital beds are occupied by people who are dying. If each person had one less crisis admission, the NHS would save £1,350,000,000 (NHS QIPP EOL workstream 2010).
(Dying Matters)
 To be precise, £15-20 Billion...
In Liberating the NHS: managing the transition Sir David Nicholson, NHS Chief Executive, sets out plans to to lead the implementation of Equity and excellence: liberating the NHS – the White Paper published 12 July 2010.
He focuses on the need for the NHS to continue providing high-quality cost-effective services, while making the required productivity savings of £15-20 billion. The Quality, Innovation, Productivity and Prevention (QIPP) programme is central to this process.

(NHS National End of Life Care Programme - QIPP,Equity and Excellence 15 July 2010)
Was it always the final solution to the problem they saw as insoluble? Long, long time ago, just after the music died, the spark of an idea spawned by some focus group in some Wilsonian think-tank in Westminster's dark halls, perhaps...

Mr. Patrick Gordon Walker’s landmark observations echo down the years.
Patrick Gordon Walker
Political Diaries1932-71
One of the results of debates such as this—we have had a number on this subject—is that it has become generally understood, and is almost a truism, how rapidly the elderly population is increasing and will continue to increase. It is probable that by the 1980s there will be about 10 million people over retirement age, and between now and the 1980s—this is a very serious problem for those who have to plan the development of the social services—the proportion of the dependent population—those under school-leaving age, on the one hand, and those over retirement age, on the other—will be rising much more rapidly than the working population, which has to produce the wealth from which we pay for social security.
Patrick Gordon Walker 1967
"In the 1980s and 1990s, alongside these developments, the practice of illegal euthanasia was spreading. Death was caused by lytic cocktail..."
Requests from the team and from loved ones are more frequent than requests from the patients themselves. Should this not make us think twice?
The debate in Belgium has omitted ‘how’ to respect the autonomy of those patients who have not asked to die, in favor of the autonomy of those who have.
In the report to the Canadian Senate, the following statement by Y. Thompson is quoted:
“By legalising euthanasia, we worry that because of social and economic pressures, the elderly and the incapacitated will have to constantly justify their right to live. It would be a tragedy if, by legalising euthanasia for compassionate reasons, we condemned part of the community to having to justify its decision to live and to take up space in health care establishments.”
When supporters of euthanasia speak of autonomy, they only consider the patient, the family is excluded from the discourse.
If a family has helped, cared for, and supported this seriously ill person sometimes for months, it is the result of a relationship that has been going on for even longer. This family is part of the patient’s life and vice versa, they cannot be excluded for facility’s sake.
In reality, families are as present as they can be, feelings fluctuate, ambivalence reigns, and what they request one day, they can regret the next. Any member of a family who makes, or participates in making, a decision that affects the patient’s life will carry this with him for the rest of his life, with all the regrets and uncertainties that go along with it. To take a request from the family literally, is to forget that suffering can make us say things we do not really mean, or whose consequences we have not thought over properly. It means forgetting that, in situations of utter confusion, we need boundaries, limits. When a family asks to have a patient’s life terminated, it is a cry for help, and should be heard as such.
Those who leapt from the twin towers did not seek death; they saw it as their only life option. 

Those who seek death, or say they do, likewise are moved only by what is, or what is perceived to be, the desperation of their plight. We fail them, not by denying them the means to put an end to themselves, but by not providing the means to regain the will to live.

When the suicide stands on the ledge, do we give a gentle push to topple them over or do we reason with them to draw them back from the brink?

Those who request euthanasia do not ‘choose’. There is no 'right' to death. Death does not debate, but demands. There is only 'right' to life.

To comply with the wish to seek death is to recognise our failure. It is also to create precedent. It has impact and consequence for us all. We are saying it’s okay; that death is a positive life choice.

When society loses the will to care; when death is always the easiest option and is interpreted as care, then life is devalued and do we stand in disgrace and disgraced.

The Guardian, 2007
In recent years, euthanasia/assisted suicide - the hopeless resort of the hopeless - has been popularised and promoted, justified and defended.

Death, as a positive life choice, has been popularised by the popular support of cultural icons for those who celebrate them to take example by.

A cross-party group of MPs accused the BBC of showing “persistent bias” in favour of euthanasia and signed an Early Day Motion which accused the BBC of conducting a “multi-million pound campaign” to promote euthanasia.

They were unable to turn the tide.

More recently, Anna Soubry and Norman Lamb have come out in support of "assisted dying" and promoted the infamous Falconer Bill.

The vulnerable, the elderly, are under pressure to justify their existence. The psychological effects are undetermined and undeterminable. Mental health impacts directly upon the physical. Many will be made to feel acutely aware that they are a burden; some will seek to make an end of it all.

To some, death might seem the only path to follow, the one resort that is left to take.

The Werther Effect

Many will be moved by example, the celebrity of the celebrated. They are about changing perceptions and perceptions have changed. They are only half way there, they say, and there is more to accomplish. Our culture is being subtly changed before our eyes such that we do not even perceive it.

A culture that turns children into death machines is evil incarnate and so do we perceive that to be. Definitions are changing, however, and we are learning the language of Newspeak.

A culture that does not need to care because to 'care' is to provide assistance to die, is that not also evil incarnate?

Further reading -
Liverpool Care Pathway - The Pro-Death Advocacy 
Liverpool Care Pathway - A Dedication, Steadfast And Sure

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