Thursday, 5 June 2014

Liverpool Care Pathway - Still Chasing The Pathway

There is no greater force than a determined and relentless pressure.

They want to change our minds. The landscape of our perceptions is changing. The Review was just a minor impediment on the pathway. They are only half way there. The bit part actors in this tragedy that has played itself out through the medical holocaust that has proceeded are still toting their drivers, hard at their purpose.

Salford Royal NHS Foundation Trust has been recruiting for an End of Life Care Facilitator for Care Homes to promote the Six Steps to Success and Gold Standards Framework. This follows on a long tradition of dedication to EoLC.

Salford Royal have fallen short of perfect...

MailOnline reported that CQUIN payments connected to the Liverpool Care Pathway were almost halved in 2012 after failing to reach targets.

This is an extract from the minutes of the Greater Manchester and Cheshire  Supportive & Palliative Care Cross Cutting Group -
Tuesday 5th. August 2008 at 4.30 pm
End of life strategy
Dr Gomm gave a very comprehensive presentation (see attachment) linking the National top Ten priority areas from the 2004 Supportive & Palliative care NICE Guidance, the recent End of Life Strategy and the publication Healthier Horizons for the Northwest. The Scope of the Strategy is as follows:
  • Covers all conditions
  • Covers all care settings (e.g. home, hospital, hospice, care home, community hospital, prison etc.)
  • Has been developed within the current legal framework
There is an emphasis on change of terminology with end of life being a much longer period of time ie the last year of life and other than the last few days and including supportive care agenda. There is also a recognition trial for some long term conditions the period of time will be longer than a year. The End of Life Care Pathway involves six steps as shown in the diagram below

This is the six steps to successful implementation of the National EoL Care Pathway Mark 2008.
  • Has been developed within the current legal framework
“Has been developed within the current legal framework...”

This is 2008. This is the pre-version 12, version 11 LCP period with no consent process and with diamorphine recommended, even in renal failure...

The End of Life Care Strategy was published in July 2008

Version12 LCP was published in December 2009 , then used in a 1 year pilot at the Royal Liverpool and Broadgreen University Hospitals Trust. (Marie Curie Institute)

This was the year the death rate increased by 50% , from 10% to 15%. The Doc Foster graph is shown here -

Further reading -
Liverpool Care Pathway - Missing The Plot
This is the County Durham and Darlington CQUIN Audit Report -

The aim of this project is to audit compliance with the following quality indicators for the End of Life Care. (Percentages in brackets represent the agreed target figures for 100% payment of CQUIN monies):

  • RMA1: Compliance with completion of the EoLCP (55%)
  • RMA2: Uptake by nursing staff on target wards of the e-learning module to support use of the EoLCP (45%)

In December 2009 a new national version of the Liverpool End of Life Care Pathway (LCP) was launched – Version 12. Following this, palliative care teams across County Durham worked collaboratively to develop a joint EOLCP document based on the new LCP. A single document was developed for use across the whole county in all care settings. The final document was agreed in autumn 2010. The CDDFT palliative care team then commenced an intensive training programme across all relevant wards throughout the acute Trust.

Following this training programme, the new V12 EoLCP was launched in a phased roll out between August and December 2010. By the beginning of December 2010, 100% of all appropriate wards had adopted and were fully trained to use the LCP. Following the initial intensive training and rollout of the new EoLCP, the palliative care team provided refresher training and updates to wards that use the EoLCP. However, this proved very time consuming for a small team and very difficult to sustain in the long term so we developed a bespoke e-learning package to support use of the EoLCP. This was launched late in 2011. The e-learning module was launched initially as a pilot on the acute surgical wards with a plan to roll out further over the next year. Records have been kept of who has completed the e-learning module from when it was first launched.

The CQUIN audit period for compliance with completion of the EoLCP document was from January to March 2012. The methodology for this audit mirrored the method used to measure compliance with completion of the EoLCP in the National Care of the Dying in Acute Hospital audit 2011.  
In forging new paths, they are covering their tracks. If you can’t find it on Google, it didn't happen. The digital world is nebulous and uncertain and truth may be extinguished with a click...

First there was the link - Marie Curie Institute.

This page discussed the LCP version 12 and spoke of LCP version11 being in use in more than 100 Intensive care units across the UK...

Then there was the broken link...

which became the redirected link -

We do not always get to choose the paths we follow and sometimes they are forced upon us.
The links of uncensored expression are being broken; the pages are being taken down; but there is still time for those to whom freedom and parliamentary government mean something to consult together. Let me, then, speak in truth and earnestness while time remains
 - Apologies to Winston S. Churchill 
Why there shouldn't be a pathway and why they want to legalise euthanasia...

This is a Rapid Response Alert from 2008 -

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.

When prescribing, dispensing or administering these medicines the healthcare practitioner or their clinical supervisor should:

  • Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient.
  • Ensure where a dose increase is intended, that the calculated dose is safe for the patient.
  • Check the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, and common side effects of that medicine and formulation.

Healthcare organisations should review local medicines and prescribing policies, including Standard Operating Procedures, to reflect this guidance.

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.

Ensure patient safety...

Is putting 3 drugs in one syringe driver safe? Is the LCP itself 'safe'?

When a patient is slapped on a death pathway, death will be an expected outcome. The death is not necessarily going to be flagged as a patient safety incident (unless it is picked up inadvertently by an independent auditor). Why should it be when the patient has been 'diagnosed' as dying? The death is catalogued as palliative.

As part of the SMART objectives, there is “timely verification and certification of death or referral to coroner” (who is not readily going to raise dispute or disagreement). A death certificate on the quick. That's handy, Harry...

These are Beacon 'Learning Outcomes' for Health and Social Care Assistants/Support Workers –
  • Be aware of the roles, responsibilities and parameters as a care worker and when to refer
  • Identify the skills, attitudes and behaviours required to help with the needs of patients and their carers towards the end of life
  • Demonstrate practical skills to help deal with difficult questions
  • Increase confidence to sensitively communicate the patient and carer
  • Demonstrate an understanding of Advance Care Planning
  • Increase familiarity and confidence with the LCP documentation
  • Understand why a Syringe Driver is used
Be aware of the roles, responsibilities and parameters as a care worker and when to refer...

But does not familiarity breed contempt and confidence a self-assurance that may barely contain hubris?

This is End of Life Care in Nursing Homes -

“On intuition: you just know, don’t you?”

Yes, yes, yes! She nearly bit his hand off to do the LCP...

Resuscitation equipment is irrelevant in this setting. Over-treatment is common...

The path less travelled we may wish to take may be snatched from us.

Additional reading -
Liverpool Care Pathway – "Six Steps To Success" 
Liverpool Care Pathway - The LKP Can Deliver

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