Monday, 7 July 2014

Liverpool Care Pathway - A Devonian EoLC

When is a DNR not a DNR? When it’s a TEP.
TEP – It’s the new DNR.

In the backwoods of olde England, in the land where, only recently, was discovered V.12...
Liverpool Care Pathway - Retracting Their Footsteps
This is Torbay and Southern Devon Healthcare in September 2012 turning on the tap to TEPs –


Is that 'To Ensure Prompt service'...?

No, it's the Treatment Escalation Plan!
This policy is two fold in its remit. Firstly outlining the Treatment Escalation Plan (TEP) and Resuscitation Decision Record (RDR) and, secondly through application of the TEP/RDR across all health sectors in Devon to ensure continuity across the health community.

By resuscitative interventions we mean treatment modalities such as antibiotics, intravenous fluids, blood transfusions, ventilatory support, inotropy/vasopressor therapy, renal replacement therapy and CPR. The TEP will be the form which will be the documentation of those resuscitative interventions which are and are not appropriate for the individual patient.
That pretty much sews up all the positive treatment options.
One way of identifying this group of patients is by the use of the surprise question, “Would you be surprised if this patient died within the next 6–12 months?” For those where the answer is “no” the TEP should be completed for patients across the health community. If the answer is “yes” then a TEP may still be appropriate although the expectation would be that the answer would be “yes” to most or all treatment modalities outlined on the form. A TEP should be completed at the discretion of the general practitioner. The patient’s physical location should not be a bar to this process.
Even if the answer is “yes” a TEP may still be appropriate...
One crucial question to be addressed in the TEP is: “Is admission to an acute hospital appropriate?” The Second Annual Report of the End of Life Care Strategy suggests that many people are still needlessly sent to hospital to die simply because care home staff do not know what else to do. We should be making every effort to decrease that figure.
TEPs are, typically, Advance Care Directives and much more.
Date of Issue: November 2012
Next Review Date: September 2014
Links or overlaps with other strategies/policies: Liverpool Care Pathway (LCP) version 11
The Mental Capacity Act 2005 is also referenced.

Version12 LCP was published in December 2009. This was issued November 2012 and they are still referencing V. 11. This may be the sticks, but this is not merely prehistoric; it is positively Devonian.

The Northern Devon Healthcare NHS Trust Quality Assurance Committee Minutes noted –
Significant Issues of Interest:
  • Item 138/13 – There has been a Devon-wide agreement to proceed with the Liverpool Care Pathway Version 12 as this helps staff and supports the training programme to provide palliative care.
This was 26 November 2013!

This is the TEP and Resuscitation Decision Record –
The Second Annual Report of the End of Life Care Strategy (DH, 2010 Life Expectancy) recognised the challenge of identifying who is approaching end of life, and acknowledged that we need to do more to improve the present situation. One of its recommendations was the adoption of the 'surprise question', where a health professional asks themselves, 'Would I be surprised if this patient were to die within the next 6 – 12 months?’
To ask the Surprise Question is the very first action required to embark upon this programme of downsized treatment. All subsequent actions/non-actions are then prejudiced by that one crucial decision to act upon that arbitrary and subjective response...

The surprise answer to the doctor’s Surprise Question...
"There was a marked deterioration, she was dying. She was being unresponsive, she was not eating or drinking. She had a haunted, harrowed expression. She just wasn't just frail, she was dying." 
The doctor is employing both clinical experience and the protocols of the GSF Prognostic Indicator Guidance to determine a diagnosis of dying.

Who is this doctor...?

Who is the patient...?

The doctor's name is Dr. Jane Barton.

Her patient's name is Mrs. Gladys Richards.

This is Journal of Medical Ethics –

The TEP explores wider outcome options than a simple DNR.

It is an Advance Directive, a My Wishes, a PACA; in the aspect of its “continuity across the health community”, it is comparable to EPACCS.
The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a wider remit of treatment options than the Do Not Resuscitate (DNR) order currently offers.
A medical holocaust has proceeded. The pages are coming down.

If you can't find it on Google, it didn't happen.

This is The National Archives –

‘Snapshots’ have been taken...

Pages are missing...

Claims are made...

This is from The National Archives –
Throughout the study period hospital was the commonest place of death-48% of cancer deaths-whereas 24.5% deaths of cancer patients occurred at home and 16.4% occurred in hospices.

The proportion of home deaths increased after 2005 whereas the proportion of hospital deaths declined. The proportion of deaths in hospices also increased over the study period. The National End of Life Care Programme in England was launched in November 2004.
The study, funded by the NIHR, claims the EoLC Programme has been positive in permitting cancer patients to have their lives ended at home and in hospice rather than in hospital.

Sweeping statements are made...
Claire Henry, director of the National End of Life Care Programme, said: "This research has demonstrated that the National End of Life Care Programme has made an important difference and has helped more people to die in their preferred place of death. Supporting people to live and die well is what we were set up to do and we have never lost sight of this.
They didn't get it all right, as Jack Jones' family will tell you!

Even so, there is a real problem here.

The EoLC Programme was about extending this bounty of mercy to ALL 'diagnosed' EoL patients; not merely cancer patients.

Independently audited figures show that HOSPITAL deaths also increased over this period (see these pages).

The EoLC Programme utilised the LCP and other EoL pathways to 'diagnose' dying and put patients to death.

This is EPACCS on the national archive –

This discusses deaths in usual place of residence (DIUPR) -
The report describes:
  • Background information for the four evaluation localities involved in the study and the ‘control’ groups used;
  • The quantitative analysis undertaken as part of the evaluation, focusing on national data for deaths in usual place of residence (DIUPR), local information on EPaCCS costs, and data extracts from EPaCCS and Hospital Episode Statistics
There are tremendous £avings to be made; and, of course, this is what it’s all about.
  • There is sufficient evidence, with appropriate context taken into account, for recurrent savings after four years to be over £100k pa and cumulative net benefit over 4 years of c.£270k for a population of 200,000 people. 
  • Independent analysis of data from the South West of England covering 1.9M people shows a level of deaths in hospital for people on EPaCCS of below 10% (compared to the England average of 54.5% in 2008-10) and savings per 200,000 population pa of £47,952 using the same assumption of £399 per saved DIUPR as above (or £177,900 using the higher cost of a hospital admission identified in this report).
The South West might be positively Devonian, but didn’t they do well...?

And here is where they ran that pilot. This is from the Gloucestershire NHS EoLC Newsletter dated January 2010, uploaded in March of 2012 –

The Pilot continues in North Somerset and Bristol. The new edited version went ‘live’ before Christmas and a template to support the implementation process have been developed. Dr Simon Smith is leading on this piece of work so more details please contact Simon Smith on
In collaboration with the Gloucestershire County Council Education Department, all Home Support Officers from the Community Steps Team have been trained during November to train their Home Support Workers in how to use the LCP within their role.
They trained their Home Support Workers in how to use the LCP within their role.

Marie Curie must take some credit, of course...

Marie Curie
Curiouser and curiouser; according to the Editor's Blog in Pulse –

GPs in Somerset were told by their CCG that they could, with the blessing of their local area team, stop reporting QOF data for the rest of the year and instead expect to be paid based on 2012/13 achievement - and that the time saved could be used as ‘thinking space’ to ‘redesign’ QOF from April.

Elsewhere, the GPC reported that Devon and Cornwall CCGs had also negotiated an agreement with local LMCs to abandon chasing QOF points that would become redundant in April anyay, with the implementation of the 2014 contract.
"Thinking space"...

It's given them time to install V. 12...

Perhaps a rethink and a rebrand in the wake of the Review?

Is this all just a tall tale or is it a tail with a sting concealed therein that is best kept concealed?

Some additional reading -

Liverpool Care Pathway - The Sum Of All Fears

Liverpool Care Pathway - Moving In For The Kill
Liverpool Care Pathway – A DNR Directive For Paramedics And First Aiders

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