Wednesday, 24 September 2014

Liverpool Care Pathway - A Cry For Caution, A Voice For Valour

Again, into the mirror darkly do we peer and must put away our childish things...

For now we see through a glass, darkly...
1 Corinthians 13:12
This is the New York Times 
The country’s system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released on Wednesday.

The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, called for sweeping change.

“The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and a former United States comptroller general, who was a chairman of the panel. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly.”
The arguments are the same; the same economics underpinning the reasoning for those arguments are mirrored in the same perverse symmetry.

The National Panel was chaired by David M. Walker, the former US Comptroller General from 1998 to 2008. The Comptroller General is the top accountant and chief fiscal watchdog. According to Wikipedia, the
"Comptroller General shall investigate, at the seat of government or elsewhere, all matters relating to the receipt, disbursement, and application of public funds, and shall make to the President when requested by him, and to Congress... recommendations looking to greater economy or efficiency in public expenditures.”
Greater economy and efficiency...

Burke Balch, director of the Powell Center for Medical Ethics, said:
“The report’s emphasis on cost-slashing will intensify, rather than calm, the well-founded fears of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths.”
The National Panel, which sat for two years, was funded by an ‘anonymous’ donor. The price tag for these ponderances came to $1.5 million. That’s some wealthy, influential and anonymous donor.

Death on Delivery
“Patients don’t die in the manner they prefer,” Dr. Victor J. Dzau, the Institute of Medicine’s president, said at the briefing. “The time is now for our nation to develop a modernized end-of-life care system.”
Ask most anyone how they would prefer their time to be when it comes and they will say they would prefer to depart this mortal coil in their own home in their own bed with their own family and loved ones about them. That doesn't mean, in the memorable words of my ageing young-at-heart US cousin, they're thinking of checking out anytime soon or they would want the doc to give up on them.

How often does death announce its coming? May death be so readily and accurately predicted? It may if provided succour and assistance.

The National Panel said Medicare should
create financial incentives for health care providers to have continuing conversations with patients on advance care planning, possibly starting as early as major teenage milestones like getting a driver’s license or going to college.
EPACCS in the USA!
The panel said that simply completing advance directives could have limited value because checking boxes does not accommodate the wide range of choices that an increasingly diverse American population wants. It said the system should be comprehensive, with medical wishes communicated to all of a patient’s providers and with access to palliative care and other support available around the clock.
This is the NHS EPaCCS Economic Evaluation Report 

The National End of Life Care Programme asked the Whole Systems Partnership to undertake an economic evaluation of the implementation pilots for Electronic Palliative Care Co-ordination Systems (EPaCCS). Eight pilots were originally identified for this programme during 2009/10, with live implementation occurring during 2011. Since then other localities have begun to implement EPaCCS and a national data set has been defined. The roll out and other information about progress in implementing EPaCCS is described in “EPaCCS, Making the Case for Change”, NEoLCP (2012).

Using conservative estimates, with a baseline setup cost of just £21K, by year 4 there is a cumulative benefit in excess of £272K projected.
Conclusion: The economic case for EPaCCS has been considered and 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. Alternative approaches to implementation as well as different starting points will have an impact on these figures as the variation in outputs within the evaluation group clearly demonstrates.

The New York Times article makes patient choice the crux of its argument.

Patient ‘choice’ is argued as a factor in the argument, but it is quite apparent that this is respected only where the goal of choice is to downsize care expectations.

This is the Liverpool Echo 

Read further -
Liverpool Care Pathway – A Compulsory Medical Procedure?
This is the New York Times 

DUNDEE, N.Y. — Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year. 
End-of-life planning remains controversial. After Sarah Palin’s “death panel” label killed efforts to include it in the Affordable Care Act in 2009, Medicare added it to a 2010 regulation, allowing the federal program to cover “voluntary advance care planning” in annual wellness visits. But bowing to political pressure, the Obama administration had Medicarerescind that portion of the regulation. In doing so, Medicare wrote that it had not considered the viewpoints of members of Congress and others who opposed it.

Politically, the issue was dead. But private insurers, often encouraged by doctors, began taking steps. 
“We are seeing more insurers who are reimbursing for these important conversations,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade association. The industry, which usually uses Medicare billing codes, had created its own code under a system that allows that if Medicare does not have one, and more insurance companies are using it or covering the discussions in other ways.

This year, for example, Blue Cross Blue Shield of Michigan began paying an average of $35 per conversation, face to face or by phone, conducted by doctors, nurses, social workers and others. And Cambia Health Solutions, which covers 2.2 million patients in Idaho, Oregon, Utah and Washington, started a program including end-of-life conversations and training in conducting them.
Incentive payments...

and another perverse symmetry -

Dundee is the home of Scotland's Dignity Care Pathway.

See -
Liverpool Care Pathway - On The Road To Dundee
Are psychometric tools to be adopted by their US counterparts to facilitate the 'conversations'?

This is NHS England 

NHS England has as its ‘vision’ a “modernised NHS – driven by a clinically led commissioning system” which “focuses absolutely on improving quality outcomes for patients”.

Take away the hocus pocus and the focus is clearly on only those treatment options which provide an outcome of sufficient ‘quality’ to justify the cost.

How often does death announce its coming? May death be so readily and accurately predicted? It may if provided succour and assistance.

The arguments are the same; the same economics underpinning the reasoning for those arguments are mirrored in the same perverse symmetry.

Read further here -
Liverpool Care Pathway – Communitarian Inevitabilities 
Liverpool Care Pathway – And The Temerity Of Arrogance 
Liverpool Care Pathway - The Bee Wee Tool
Macmillan are running a hard-hitting campaign.

Macmillan are trying to make good the bad publicity the Review has reflected upon them by criminal association. They are trying to make good by capitalising on the good reputation of the brand.

Macmillan were themselves promoters and practitioners of what has been called a "Toxic Brand" – the Liverpool Care Pathway. They were up to their eyeballs in complicity. They bear the same guilt. The Review iced over what was wrong. It wasn’t at all that the Death Pathway had been misinterpreted and misapplied; it was that it was applied at all.

They imposed the Death Pathway. Is there no penalty to be imposed?

Macmillan are running a hard-hitting campaign. It is almost as if the alarm buttons hit during the clamour of newspaper reports and the outcry of protest by the families and loved ones of the victims disgracefully dismissed as ‘anecdotal’ in Parliament and which finally prompted the infamous, insufficient and ineffectual Review had never happened.

They are not carrying on where they left off; they never ‘left off’.

What defence have they? Like Hitler’s henchmen, can they say they were following orders? They were following the directives of the protocol of treatment advised by the Pathway.

Death is unpredictable unless we make it predictable. And it was.

Make it so...

Be Macmillan.

Sunday, 7 September 2014

Liverpool Care Pathway - A Perverse Symmetry

Ready, Steady... Gone! All menschen are equal, but some menschen are less equal than others!

They induce birth and, via EoL Pathways, induce death. Practitioners of the Pathways have actually declared themselves ‘Soul Midwives’.

Is it a symmetry that they perceive at life’s coming and life’s going? They have defined what they describe as ‘brain death’; now, do they seek ‘brain birth’?

Is there a point that defines what they may describe as the beginning of the human child? Is there some neurological marker that defines self-awareness and selfhood?

There are those who have suggested ‘personhood’ may actually cease before that point of clinical 'parturition' when all brain activity that can be determined has ceased. They use this determination to suggest that organ harvesting may commence more usefully at an earlier stage.

Here, it is described as 'permanent unconsciousness' -
Liverpool Care Pathway - Redefining Death 
Adopting the concept of 'personhood', it is conceived that, as their condition becomes more aggressive, a person suffering from Alzheimer's may cease to be a person and lack 'personhood'.
"Progressively, we will accept organs from the brain-dead, from former persons who are permanently unconscious,from former persons who are in persistent vegetative state,and from patients who have lost their personhood to Alzheimer's disease."
There are those who have suggested ‘personhood’ may actually begin beyond that point of clinical parturition when the child begins an independent existence.

This is -
Liverpool Care Pathway – The Innocuous Euphemism 
And this is The Telegraph –

There is a perverse logic to this quest for symmetry. It is a quest for that elegance and meaning that is lacking in the materialist logic of humanism; it is a continuance of the continuum of that same dialectical materialism that gave birth to the terrible political despotisms of the 20th century.

It is a quest to seek meaning and balance at life's beginning and at life's end.

It is a cold, hard logic that stands beyond any human perspective. It is a science without a soul.

The 19th Century saw an imperative to define everything in scientific terms. Political scientists attempted to reduce history itself - the course of human events and society - to a series of definable, linear stages.

The State apparatus of terror of the National Socialists under Hitler mirrored that of the CPSU under Lenin, honed by Stalin, Hitler's infamous ally in the invasion of Poland and the Baltic republics.

These are not 'Doctors of Philosophy' but Doctors of Dogmatism. The political dogmatism of the 20th Century is become the religious dogmatism of the 21st. God help us.

With the same perverse quest for symmetry, the 'quality of life' is adjudged wanting and the ‘quality of death’ is determined and enforced. It is elegance and meaning. 

This is Yorkshire and Humber EoLC Leadership Board 
The national QIPP work stream focuses on improving systems and practice for identifying people as they approach the end of life and planning their care. National levers include NICE guidance, a range of quality standards, markers and measures, the commissioning guide and Routes to Success for end of life services. These focus on implementing key tools such as the Liverpool Care Pathway (LCP), Preferred Priorities of Care (PPC) and Advance Care Planning (ACP) as well as improving co-ordination of care across sectors through developments such as the Electronic Palliative Care Co-ordination System (EPaCCS).
This almost 'religious' observance is reflected, likewise. As the religious donate their tithe of 10%, these medical ethicists, without qualm or compunction but with scientific logic, demand their 1%. That is the statistical quota it is their 'ambition' - obsession - to find...
The Gold Standards Framework suggested 10-15% deaths are classed as ‘sudden’, and around 85% of deaths are linked to cancer, organ failure and general frailty. Whilst not all deaths from cancer, organ failure and general frailty would be expected to die within 12 months, many of these should be included on the register and as part of end of life planning.Given that approximately 70-80% of deaths are potentially classed as ‘expected’ deaths, it is anticipated that the proportion of people on an end of life register who die each year should be higher than the current regional average of 19%. Including 50% of patients on an end of life register is seen as an ambition for organisations to work towards achieving. The 75% line on the chart overleaf has been included to mark the 70-80% of non-sudden (i.e. ‘expected’) deaths. The PCT closest to achieving the ambition within the region is Rotherham PCT with 28% and the furthest North Lincolnshire PCT (10%). Whilst we are dealing with relatively small numbers of patients, and not all deaths would be expected or meet the ‘3 trigger criteria’ for inclusion on an EOL register, it is anticipated that prevalence rates should be higher than current data suggests.

The PCT closest to achieving the ambition within the region is Rotherham.

Rotherham, where the perverse dogmatism of political correctness reigns supreme over rational morality, is top of the list.

A whole generation of young doctors has been conditioned and programmed to accept the validity of what is an unscientific premise: that it is possible with a degree of certainty to identify various presenting signs as an indicator of dying.

It is a statistical certainty that every person in their elder years is 'approaching the end of life'. Old age is a 'terminal condition'. If a person of elder years falls seriously ill, however, that does not mean that they are terminally ill; it means only that they require that much more care and attention to improve or to maintain their condition.

This is rather typical of modern science: having decided that something is so, they then seek the evidence to substantiate it is so. The decision to determine EoL and to 'diagnose' dying is a self-fulfilling prophecy.
They have your card marked. Just when you need that extra TLC, they wind down the care and 'make you comfortable'.
"There are dangers in grouping patients labelled 'terminal' in institutions, because diagnoses can be wrong. There is a risk that if all the staff in an institution are orientated towards death and dying and non-intervention, treatable illness may be overlooked. Not everyone who is referred for terminal care proves to be terminally ill, and no physician should accept such a diagnosis without the evidence personally."
Dr. Gillian M Craig Consultant Geriatrician
There are associated dangers, then, in grouping patients labelled "terminal" onto EoLC death lists.
"Have your local practices identified the one per cent of their practice population who may be likely to die in the next year?"
- ACP Toolkit
Already, the focus is on downsizing care responses. Patients so identified are groomed at the primary care stage, by GP or District Nurse, to lower their sights and downsize care expectations, to see the glass half empty rather than half full.

Local practices identify their one per cent quota for the cull. Doctors assess patients during routine consultations. Those who present 'indicators of frailty and deterioration' are added to the lists. The elderly are a priority to consider. They are weeding out the runts.

These grooming skills are an art...

Dying Matters
GP practices are awarded accreditations.
The practices received the quality hallmark because they demonstrated ‘substantial improvements in a number of key areas - crucially identifying more patients, not just those with cancer, as being in the final months of life’.

The changes mean patients are more engaged in discussions about their end of life care, enabling more people to die in their preferred place and more families to receive bereavement support. Areas of improvement displayed by the practices included: an increase in the number of patients on the end of life register with a non-cancer diagnosis; an increase in the number of care home patients on the register; and an increase in the number of people dying in their usual place of residence.
The NHS (National-socialist Health Service) is pressing ahead with a diligence and determination to capture the quota for inclusion on the EoL register and has compiled a questionnaire. When the visiting District Nurse came out to see his mum, however, even Roy Lilley called this questionnaire 'callous'.

Roy Lilley is a person 'in the know'. He really should know.

Norman Lamb knows. He launched the toolkit...

Dying Matters
The National End of Life Care Programme (NEoLCP) has launched a new toolkit to help care providers facilitate Advance Care Planning with people nearing the end of life.
The kit, entitled 'Advance Care Planning: It all ADSE up’, aims to give care providers the information and guidance they need to feel confident in supporting the Advance Care Planning process. 

District nurses and hospital consultants feed back information. Patients in care homes are "actively considered for the register". Patients on the register are "less likely to be subject to treatments of limited clinical value" and are groomed to accept this.

The toolkit is designed to instil confidence.

Nice employs SMART definitions. “People approaching the end of life are identified in a timely way.” (NICE Quality Statement 1)
Identification of people approaching the end of life may be initiated by either health or social care professionals in any setting. Professionals should discuss the benefits of being identified and the use of a register, EPaCCS or equivalent system with the person and their families and carers.
ELCQuA is an End of Life Care Quality Assessment Tool. This tool employs a RAG (red, amber, green) assessment to indicate progress in implementation.

Ready, Steady, Go.

This is the way forward. You are assessed and adjudged accordingly. These are 'Quality Outcomes' to obtain accreditation. 
Green Definition: EPaCCS, GSF or other service improvement system in place throughout organisation to record people approaching the end of life.
 Amber Definition: System in place to record but not fully implemented.
 Red Definition: Systems not in place
The tool is for use by PCT Commissioners, Local Authorities, Primary Care Services, Acute Trusts, Community Services, Care Homes, Ambulance Services, Out of Hours, Domiciliary. Clearly, there is a coercement to ‘get out of the red’ asap and sign up those punters for EoLC.
Green Definition: 60% or more
 Amber Definition: 40-59%
 Red Definition: < 40%
These are incentives, plain and simple. This is a motivator to get them signed up and on board.

Social Care workers may use these tools with 'confidence'. Yes, it must be a great relief to know that your mum has been identified, Mr. Lilley.

This is just ACE - Accreditation and over-Confidence leads to Errors.

The page at Advance Care Planning: It all ADSE up would tell you more but it has been archived.

See instead -
Liverpool Care Pathway - Lamb's Move And Mate...
Statistics are always open to interpretation. Data is a useful basis to construct future projections. When the variables multiply however, so does inaccuracy creep in. Data modelling is a guide; it cannot be used as the rule. Data modelling, however elegant, indicates the trend, the epitome, not particular outcomes.


Babies are aborted because they are not wanted or are an inconvenience. It is pro-choice. It is a woman’s right to choose. According to Kelly Hills in The Guardian, being pro-life actually makes you ‘less of a lefty’.

Richard Dawkins has played the Down's Syndrome eugenics card.

This is Mail Online -
Professor Dawkins said: 'Yes, it is very civilised. These are foetuses, diagnosed before they have human feelings.'
He later added: 'Learn to think in non-essentialist ways. The question is not "is it 'human'?" but "can it suffer?"'

Lefties I know equate eugenics with the Right and Hitlerian concepts of racial purity. So then, Ms. Hills, 'choice' yes, but on the grounds of eugenics and - let's face it - racial purity and 'cleaning up' the gene pool?

William Beveridge, was appointed to chair the committee set up by Arthur Greenwood which brought about the NHS (National- socialist Health Service).

Beveridge was one of those 'advanced' thinkers prominent with the Fabians in the LSE and an advocate of eugenics. Well, well, well.

Read further here -

Liverpool Care Pathway - Appointment With Death

Further further reading -

Liverpool Care Pathway - Persons, Personhood And Non-persons
Liverpool Care Pathway - The LCP Hit List
Liverpool Care Pathway - One step Beyond The Pathway

Last word –

Dying Matters has reported that too many people are dying in hospital from cardiovascular disease.

Most patients would consider that when they fall seriously ill, for whatever reason, the doctors will do their level best for them and that this comment reflects a concern that more should be done.


This comment reflects the EoL Strategy requirement to get them on that register and signed up to a death wish plan.

What matters above all else is meeting those EoL quality outcomes.

What matters, above all else, is dying...

Because, above all else, dying matters!
No, no, no...
Living always matters.
Life is a gift. It is not a nuisance to cut out or a burden to put down...
         Liverpool Care Pathway - The Joy Of Living