Wednesday, 28 May 2014

Liverpool Care Pathway - In The Beginning Was The Pathway...

"I am the way and the path and the death... In my Father's house are many side-rooms; and I go to prepare a place for you.

John Bingham reports in The Telegraph that cuts in care for the elderly and disabled are putting services under ‘unsustainable pressure’ -

The National Audit Office found that despite a Government pledge to protect social care from the impact of austerity, spending on help for older people in England plunged by 12 per cent in just two years in real terms.
While councils have spoken of protecting services by focusing on other cost-saving measures, the NAO concluded that the vast majority of the reduction had been achieved by cutting the amount of care provided by tightening the eligibility rules.
Yet the cuts come at a time when need is greater than ever with the number of people over the age of 85 growing at a faster rate than the overall population.
Even the Government does not know how long the system can continue to cope with the pressure from rising demand but declining funding, it warned.
This is not new news. The EoLC Strategy permeated every section of society. Last year, the CCGs took the helm. We are only half way there. Do ideas already floated require refloating? Are they trying to tell us something? Is it a repeat fiasco of the independent auditor misinterpreting the figures as when Doc Foster reported a 'ten-fold increase' in hospital palliative deaths?

Guys and St. Thomas', home of the Amber Care Bundle and very proud of their record, were actually hauled over the coals in the Doc Foster report. See, for instance, -
Liverpool Care Pathway - Missing The Plot
See also -
Liverpool Care Pathway - Appointment With Death
So, the National Audit Office warns that spending has fallen by 12%.

Caroline Abrahams, Age UK national director, is concerned. Age UK, remember, backed the LCP. Age UK is currently working with a pro-euthanasia pressure group, Compassion in Dying.

These cuts were long planned and budgeted for as the Municipals acknowledged their role in EoLC and were required to accept cuts in central funding. This is Birmingham Council -
Birmingham City Council will be opening the consultation for the 2013/14 Budget next month against a backdrop of greater than previously notified grant reduction from national government.
Edinburgh Council, likewise, had to budget for required savings of almost £13 million in the last financial year. So, what's up Doc? It looks like the required spending cuts are being made. Care expectations are being downsized accordingly. The EoLC programme is biting all round. It is serving its purpose.

See -
Liverpool Care Pathway - The Micawber Principle
Studies demonstrate death to be a key focus of the day to day business of hospitals. And they are only half-way there.

This is a society geared to downsizing great expectations of life.

This is The Telegraph –

The Telegraph headlines: “Stop medicating the elderly and let them die naturally.”

Let someone “die naturally”. They make themselves sound so reasonable, compassionate.

Whatever age you are there's many an illness, if it isn't medicated, will most certainly cause you to die 'naturally'. Are the rules determined by your positioning on the Complete Lives priority curve?

Jane Ellison has responded to Mr Nicholas Brown at Question Time that permission is not required to slap a DNR on a patient’s file...

“Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team and documented carefully.”

Studies demonstrate death to be a key focus of the day to day business of hospitals. And they are only half-way there.

This is a society geared to death.

Caroline Abrahams, Age UK national director, is concerned...

The Lakhani Recommendations have downsized CPR. Are these the Byatt Recommendations to downsize treatment?
Writing in the journal Evidence Based Medicine, Dr Byatt said: “The data strongly suggests that we are over-treating many over-80s. 
“The largest trials of antihypertensive therapy and statins in this age group show at best a marginal clinical reduction in stroke and very modest clinical reduction in other cardiovascular end points.” 
Dr Byatt said studies have shown that: “these medications are greatly over-prescribed in the healthy elderly, and largely irrelevant in the frail elderly.” 
“In my experience, it is not uncommon in the oldest of these often frail but relatively disease-free patients, to see death as the next natural event in their life, especially welcome if they have outlived their peers,” he added.
“However this cohort is often deferential to the doctor, whom they frequently want to please or at least not upset. - The Telegraph
When someone visits the quack, it’s usually because they have a health issue they would like addressed. They may be happy or not happy with the treatment, but to extrapolate that dissatisfaction to demonstrate a preference to 'die naturally' is, frankly, bizarre.

Dr Madina Kara at the Stroke Association says that the success of statins and antihypertensive drugs has been proven and that they save 7000 lives each year.

You may dispute a study or its validity...
The recommendations are based on clinical evidence showing that stricter guidelines provided no additional benefit to patients, explained guidelines author Dr. Paul James, head of the department of family medicine at the University of Iowa Carver College of Medicine.
 "We really couldn't see additional health benefits by driving blood pressure lower than 150 in people over 60 [years of age]," James explained. "It was very clear that 150 was the best number."
 The American Heart Association (AHA) and the American College of Cardiology (ACC) did not review the new guidelines, but the AHA has expressed reservations about the panel's conclusions.
 "We are concerned that relaxing the recommendations may expose more persons to the problem of inadequately controlled blood pressure," said AHA president-elect Dr. Elliott Antman, a cardiologist at Brigham and Women's Hospital and a professor at Harvard Medical School in Boston.
 In November, the AHA and ACC released their own joint set of treatment guidelines for high blood pressure, as well as new guidelines for the treatment of high cholesterol that could greatly expand the number of people taking cholesterol-lowering statins. -
You don’t use rule-of-thumb pathways. You don’t treat the herd; you treat the patient, the individual in front of you.

Japanese report from 2002 recognises this and actually appears to pre-empt the findings of the recent US report...
Hypertension in adults is defined as systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90 mmHg or more (14). However, since blood pressure changes with age, the blood pressure level to be treated by antihypertensive drugs and the therapeutic goal pressure should be established separately for the elderly.
The treatment guidelines for hypertension published in the USA and Europe are essentially guidelines and, whilst a useful reference point for the control and treatment of hypertension, it is not appropriate to adopt them indiscriminately to Japanese hypertensive patients without consideration of the differences in genetic and social background.

So, what's all that about 'dying naturally'...?

It is all about promoting a landscape of downsized healthcare. The idea becomes integral to it. It is about denying and removing the possibility of hope. It is surrendering as vain and inappropriate Canutian endeavours all attempts to salvage and to preserve life.

No, Lady Jane, these doctors lack the capacity to understand or respect the courage of the human spirit, this day and every day, to live life and live it fully through another day, and they would give up on you, especially when you need them most.

God help us, this ilk would have sold us out to those 'thugs of Nazis' as my dear mum called them. These Quislings would have seen it all as futile and Canutian to attempt to hold back the Nazi horde. Heavens, we would today be ruled and overrun by a German led Europe...

And how would they have met the outrageous bravery of a Douglas Bader determined to reach for the sky and fly again? It is not a matter of refusing to face up to the gaping maw of death but all about confronting it. It is all about doing all you can until there is no more you can do.

Do you stand shoulder to shoulder with the suicide to urge them back from the brink or, side by side, do you tip them over the edge, with or even without their urgings to do so, to comply with some self-assessment of "best interest"?

This is the Economic and Social Research Council –

We are the UK's largest organisation for funding research on economic and social issues. We support independent, high quality research which has an impact on business, the public sector and the third sector. At any one time we support over 4,000 researchers and postgraduate students in academic institutions and independent research institutes.

The social architects are ever hard at work behind the scenes, manipulating and moulding. Society is but putty in their hands. When the ESRC makes funding available it is understood that it is toward matters of some considerable import.

The ESRC has been funding research into 'terminal sedation until death’ at Southampton University. Professor Sheila Payne is a member of the study group.

The Research Project discusses -
...the differences and similarities between 'continuous deep sedation until death' and euthanasia. Across Europe, the law surrounding end of life care has developed in significantly different ways.

For example, euthanasia (at someone's competent request) is now legally permissible in the Netherlands and in Belgium, but illegal, although subject to fierce debate and a review in the UK. There are some figures from research which suggest that the use of 'continuous deep sedation until death' may be used as a 'substitute' for euthanasia in some cases.
It is stated that continuous deep sedation until death may be used as a substitute for euthanasia. The UK data set is comprised of surveys completed by UK medical practitioners. This will be data from use of end of life pathways such as LCP, at home, in hospital and in hospice.

See -
Liverpool Care Pathway - The Side Effects
Jane Ellison has responded to Mr Nicholas Brown at Question Time that permission is not required to slap a DNR on a patient’s file...

“Decisions about CPR are sensitive and complex and should be undertaken by experienced members of the healthcare team and documented carefully.”

Ideas jostle for our attention, a flotsam and jetsam which has been floated over many years and has become a flotilla. Its course already charted, it hastens rapidly to join an Armada that threatens to overwhelm what last vestiges of common decency there are left to sustain us. This Armada that has gathered has put up a barrage and now threatens us with its blockade.

What is Beacon? Beacon is...

Beacon is a GSF accreditation conferred by the GSF itself, as are its other standards of accreditation. These are: Beacon, Commend and Pass.

What is Beacon? Beacon is...

- Beacon
Beacon is a Training Partnership of the SCC and the Learning Enterprise. It is aimed at care assistants and support workers to identify and support patients for EoLC, familiarise themselves with LCP documentation and with ACPs.

They’re teaching support assistants and support workers using Ellershaw’s evidence base...

Ellershaw’s own team can't get it right.

Mr. Ellershaw... I won't call you 'Doctor' or 'Professor' or whatever else you profess to be; you should be struck off - wiped off! - every medical register for this great wrong that has proceeded.

Mr. Ellershaw, I will say just two words. These two words are a name. That name is Jack Jones.

Further reading -
Liverpool Care Pathway - These Disgusting People
Liverpool Care Pathway - Onward And Upward
The experienced lack the experience.

"Features of opiate toxicity may be interpreted as un-controlled pain, leading to the administration of more opiate medication. The consequences are increased sedation, dehydration and further toxicity." (O’Neill and Fallon, 1997).

From the 
BMJ archives -
"... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."
What is Beacon? Beacon is...

The BEACON Project is bringing UK EoLC practices to VA Medical Centres and CLCs (Community Living Centres). CLCs are Nursing Homes designed to resemble ‘home’ as much as that is possible in a community setting. The Philadelphia VA Medical Centre, for instance, operates a 135-bed CLC. Beacon is said to be having a “positive” effect. In EoLC terms, that’s quite frightening.

BEACON stands for Best practices for End of life care And Comfort care Order sets for our Nation's veterans.

Further reading -
Is this the NCPC’s 'Dying Matters' programme...?
"We only die once, and therefore there is only one opportunity to provide excellent care to a patient in the last days of life." 
It could be, might as well be, but it isn't.

This is Science Newsline writing about BEACON –

There is much value in training hospital and nursing home staff in the basics of palliative care to make the last days of a dying patient's life as comfortable and dignified as possible. So says F. Amos Bailey of the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham in the US. Bailey is the leader of a study¹ that saw the benefits of introducing palliative care strategies, typical of hospices, within the setting of Veterans Affairs Medical Centers. Although conducted with US veterans in mind, their findings can have a wider impact, as most Americans will eventually die within the inpatient setting of a hospital or nursing home.
The results of the BEACON trial indicate the strategy's potential for greater dissemination to improve end-of-life care for the thousands of patients who die each year in inpatient settings.

"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."
The Comfort Care Order Set (CCOS) has been developed for veterans diagnosed for EoLC in acute care wards and CLCs.

The multi-component intervention included training hospital staff on how to identify dying patients. Over 1,620 staff members received training.

The trial found ‘modest but statistically significant’ changes in several processes of care. These included more orders for Opioid medications, Antipsychotics and Benzodiazepines such as Midazolam...

The EoLC programme is all about downsizing care. The trans-Atlantic links are documented in these pages.

A national scandal is reported in Pine Island Eagle –

In the US, approximately 3 out of 4 people die in institutional settings; half of all deaths occur in acute care hospitals, a quarter in nursing homes.

More is being said by what is not being said.

Around 25% elderly Medicare patients are veterans. There is a black hole of demand the resources simply cannot fill. Unmeetable expectations are being placed on diminishing resources. Rolling out an EoLC programme and downsizing care expectations is imperative, therefore, and for provision of care of the dying in inpatient settings to take priority over curative care options for patients 'diagnosed' to be at Life's End.

Here's some Communitarian reasoning from US liberal commentator and blogger, Matthew Yglesias -
"Read Frakt for a bit of an account of how this arises operationally, but what I think is more important is that it arises on a meta-level because we have such a fragmented health care system. When your health care spending is all in one bucket, then at any given level of spending you face a question about how to allocate it. And when allocating spending between young and old, you're cross-pressured. On the one hand, older people have more need for health care services which militates in favor of allocating spending to them. On the other hand, providing health care services to younger people generally offers better value in terms of years of life and quality of life saved. A 25 year-old who's in a bad car accident can, if found in time and treated, still live a very happy and healthy life. If you're 95 and get into the same car accident, then treatment is going to be much more difficult, recovery will be much less complete, and in the grand scheme of things you're not going to live very long anyway."
When you’re on the upper end of that priority curve, you just don’t count for much, then. You don’t get shifted to the front of the queue for treatment anytime soon.

Additional reading -
Liverpool Care Pathway - The State Rules. Okay?
Liverpool Care Pathway - Reja Vu

No comments:

Post a Comment