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.

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