Tuesday, 29 December 2015

Liverpool Care Pathway - End Of Year Life Café...

"And here is truth: How may you tell when will be the moment of death? God alone knows!"

Here is Life Café...

This is The Mirror –
Francesca and Lee Moore-Williams, 41 and 44, cried as they held Bella’s hand and took one final photograph before her ventilator was switched off.

The couple even signed a Do Not Resuscitate form meaning no special measures would be taken to keep her alive.

But just 30 minutes after their heartbreaking goodbye the 18-month-old tot, who doctors had given up for dead, began kicking and screaming.

Bella has continued to recover and five months on she is well enough to celebrate Christmas with her family at home.
Dad-of-two Lee said: “I was holding her hand knowing there was going to be a little last breath.

“I could feel her hand dropping and it went down but then she started gripping my finger.

“She started moving on her own and then her machine started going off.

“The doctors then changed everything to try and keep her alive.”

Francesca added: “It’s just amazing. It’s like we have won the lottery.

“She made our family complete and it’s great to see how well she is doing.

“When she says ‘mama’ it melts my heart.”

On July 21 Francesca and Lee said an emotional final goodbye to their daughter after taking prints of her hands and feet as a memento.

They also took a final picture together with their son Bobby, five, before the ventilator was switched off. 

Francesca explained: “The whole family came in one by one to say their goodbyes.

“I just kept sitting there thinking ‘why us’. It was heart wrenching.

“I will never, ever forget that moment where I had to say goodbye to my daughter.”
More reflective Life Café from Belfast Live 

They say the best gifts come in small packages.

So, when tiny baby Lewis Hall finally got home after almost two months in Belfast's Royal Victoria Hospital, it was the best Christmas present his parents could have wished for.

The premature tot was born in August - 11 weeks early - weighing less than a bag of sugar.

Every day in Northern Ireland seven babies are born too soon.

Some arrive as early as 24 weeks and weighing as little as one pound.

The charity TinyLife has volunteers in the region's seven neonatal units to offer practical and emotional support to the parents of premature and sick babies through the family and support service.

TinyLife's hospital to home volunteer visitation service provides breast pumps, tiny gyms, baby massage and sensory sessions as well as family activities and support groups.

Mrs Hall added: "TinyLife were amazing. They were the people who were there from Lewis was a day old.

"I don't know what I would have done without them."

She has also paid tribute to the medical staff at the RVH.

Anyone wishing to donate to TinyLife can log on to justgiving.co.uk/TinyLife
Whatever ‘signs’ are looked for to determine outcomes, all are ultimately fallible. How may signs, whether GSF or SPICT be used to pintsize care expectations and to see the glass half-full?
"If I should ever seek death - there are several times when my progressive condition challenges me - I want to guarantee that you are there supporting my continued life and its value. The last thing I want is for you to give up on me, especially when I need you most."
- Lady Jane Campbell
Life is precious. Living matters.

This has been Life Café.

May the New Year bring us Hope and Hope keep our Faith resolute and strong.

Sunday, 27 December 2015

Liverpool Care Pathway - End Of Year Review Of Outcomes

Nothing changes but the name; nothing changes but it stays the same.

In July, NICE published its draft guideline for consultation with stakeholders...
Liverpool Care Pathway - Not By A Long Shot
This took the same line as the Neuberger Review:
These are not necessarily direct consequences of following the LCP approach, rather a poor implementation of it and without ensuring adequate training and supervision of frontline staff.
It wasn't the Pathway; it was the implementation of the Pathway.

It is worth commenting that, if the training was inadequate, the person in charge of the training holds some grave (grave being the operative word) responsibility for that.

Macmillan Newsletter describes an e-Learning package for End of Life Care and the Liverpool Care Pathway -
"Nearly all health and social care staff need training of some sort in end of life care. A new e-learning package aims to offer just that"

In the context of End of Life training, it is surely inappropriate and, quite simply, offensive to describe the training offered as being "easy, fun and free". It is so described in the Macmillan Newsletter.

Dr. Bee Wee, National Clinical Lead for e-ELCA, certainly seems to be 'having fun' in this photo-shoot picture from the Newsletter.

"Easy, fun and free" is almost as crass as that infamous 'Mission Impossible' slide from Carmel Wiseman at Bolton Medical Learning Zone.

Dr. Bee Wee, as President of the Association for Palliative Medicine, was responsible for the catastrophic programme of training. See -
Liverpool Care Pathway - Lost Upon A Pathway
Following consultation, a final document was pencilled in for December...
Liverpool Care Pathway - New Priorities For Care
NICE guideline

the final document, 'Care of dying adults in the last days of life', was published on the 16th December –
Recognising dying

Recognising dying can be challenging for health and care professionals. There is often uncertainty about how long a person has left to live and the signs that suggest that someone is dying are complex and subtle.


Some health and care professionals are uncomfortable discussing how long someone has left to live, and sometimes do not have the skills and confidence to give difficult news or talk about the dying process. Adequate training and continued support is important to help health and care professionals to communicate sensitively and effectively.

Shared decision-making

Effective shared decision-making can help to ensure that people get the right care in the last days of their life. Health and care professionals can help to achieve this if they have the right communication skills, and have a good rapport with the dying person and those important to them.
This is really same old same old. What is offered, priority or pathway, is still a protocol.

The document asks:
What can health and care professionals do to help?
...and references the same e-Learning training programmes at e-ELCA -
Use training programmes such as e-Learning for Healthcare's e-ELCA to improve their knowledge and skills.
Whilst recognising the fallibility of diagnosis, the document makes reference to the ‘dying person’ throughout.

By describing the person as a dying person you have already classified that person and taken that first step to downsize their care options.

Here is truth: How may you tell when will be the moment of death? God alone knows!

Here is Mail Online –
Doctors are still following the abolished Liverpool Care Pathway because they think they know best when it comes to caring for dying patients, the health watchdog has warned.
This same ‘health watchdog’ recommended the LCP as best practice.
In the worst cases the LCP, which was introduced in the 1990s, saw patients denied sustenance for several days before their deaths, while others were written off even though they could have recovered.
A medical holocaust has proceeded and no-one is to be brought to account.
The Government ordered an independent review in 2012 which recommended that hospitals abolish the practice by July 2014.
Denise Charlesworth-Smith took the case of her father, murdered on the LCP, to the highest in the land and only out of that came the Neuberger Review into how the LCP was used in practice.
Earlier this year nurses and other experts gave evidence to MPs on the health select committee that the pathway was still being used by hospitals ‘under a different name’.
We know all about The Wirral et al...
The Wirrall
They included Adrienne Betteley, an expert in end-of-life care for the cancer charity Macmillan, who said: ‘There are areas that I know that have almost tweaked the original document and called it something else – and that is very concerning.
Really Adrienne, Macmillan was among those which promoted, supported and vociferously defended the LCP even in the face of massive evidence of the medical holocaust that was proceeding and which was dismissed as anecdote in parliament...
Liverpool Care Pathway - "Anecdotal And Without Substance"
In response to those who can't kick the habit and continue to use the LCP and its scions, Professor Ahmedzai says, “Woe betide them.”


Nick Cartwright writes in the Huffington Post –

There were undeniably bad decisions; there will undoubtedly be more in future. However, ditching the LCP is akin to accepting the excuses of the bad workman who always blames his tools and redesigning his tools for him. Odder still would be to accept the bad workman's excuses and rename his tools rather than redesigning them, yet NICE are retaining many of the core principles of the LCP.

My point is that more rules, or different rules, are rarely the answer.

Mr. Cartwright, the problem was, quite simply, the rules.

And is that your summation of the deaths by LCP, that there were undeniably bad decisions and there will undoubtedly be more in future...?

God help us...

GP's are still marking the cards of their one percent to downsize care options.
Some GP practices, such as those with GSF accreditation, are identifying patients earlier. Many are reaching their 1% estimate of population deaths with the key ratio – the number of patients on their QOF palliative care/GSF register over the number of patients in their population – and most of these patients are being offered advance care planning. 
They demonstrate what is possible to achieve and how this links up with the care of frail elderly patients and admission avoidance. 
The CQC will be asking practices about this earlier identification 
GP Online
The NCPC, which also rabidly promoted the LCP, also now backs the NICE guidelines which, as Mr. Cartwright points out, are not fundamentally different from those of the LCP.

The Government published its NHS National End of Life Care Program in 2008 and invited the NCPC to groom the British public into accepting the idea of dying as a positive life choice. Out of this was formed the Dying Matters Coalition and the Death Cafés. The NCPC led the Coalition from 2009.

The Department of Health committed to investing 286 million pounds over the two years to 2011 to support implementation of its National End of Life Care Strategy and implementation of the LCP.

Doctors do actually use flow charts in diagnostic procedure. It is the fallibility of the flow chart that, like that of the machine, it is a linear, yes-no thought process with no what-if.

In getting the machine to think like the human, humans are beginning to think like machines.

Intuitive/iterative programming is making strides but our health professionals are still stuck in the mud of linear flowcharts. Once your card is marked, the options further down the line are already prejudiced.

Last word -
“You don’t need a lot of intensive scientific training to encourage people to show respect and give compassionate care,” he said. [Prof Ahmedzai]

But Prof Patrick Pullicino, one of the first medics to raise concerns about the Liverpool Care Pathway, said the new advice was as bad as the approach it replaces.

He criticised the attempt in the guidance to identify “signs” that a person might be dying, saying once patients were “diagnosed” as facing death it inevitably meant their treatment was changed and their death more likely.
 The Telegraphl

Monday, 14 December 2015

Liverpool Care Pathway - 'Tis The Season To Be Hopeful

This season is and is not about many things and nothing, depending on what is your faith or belief.

Whatever is your faith or belief, the spirit of giving is not contrived; it is a genuine thing cemented in our common human psyche. Commercialism may seek to take advantage and profit from that spirit but with no commerce there is no economy.

The spirit of Christmas transcends the spirituality of those who celebrate it in faith and belief.

Some Christmas Life Café, then, with a story of the positivity of hope, of always looking at the glass half-full, for to downsize expectations is to surrender to despair.

This is abc News –

Firefighters found Sa'fyre next to her father, who used his body to shield her from the flames. It took Sa'fyre 10 months to recover from the fire in the hospital. Dolder credits Sa'fyre with helping her get over the death of her 18-year-old daughter, who died three years before the fire.

“She’s a living message to people that there’s hope, and no matter what you can get through anything,” Dolder said. “That’s why we share Sa'fyre with everyone.”

“She helped me move forward,” Dolder added. “I will never be able to repay her.”

The magic of Christmas is the ability to spread cheer and joy despite the hardships one faces, and that’s the message one determined little girl is spreading this holiday season with a simple wish.

Sa'fyre Terry had lived in and out of foster homes when an arson fire killed her father and three siblings on May 2, 2013, in Schnectady, New York. She was 5 years old at the time. The blaze burned 75 percent of her body and eventually claimed her right arm and left foot. Now 8 years old, she said the only gift she wants this Christmas is cards from all over the world, her aunt, Liz Dolder, told ABC News today.

Dolder brought home a gold metal Christmas tree stand from a Goodwill store in Schnectady for $4 and Sa'fyre told her that she “couldn’t wait” to fill it with Christmas cards. That’s when Dolder, who has custody of Sa'fyre, posted a message to Facebook requesting for cards to be sent to a local post office.

“When the first card came in, it was like she won the lottery,” Dolder said. But she didn’t want Sa'fyre to get her hopes up, so she told her they would probably get “a few” more. Instead, dozens more came.

“This thing has taken a life of it’s own,” she said.

If you would like to send a Christmas card to Sa'fyre, address your card to:
Sa'fyre Terry
P.O. Box 6126
NY 12306
Christmas has 'taken a life of it's own'.

If this season is about anything, it is the celebration of light and love and life. It is about the light love brings and the love of life.

That is not to say that death may and death does intrude at any time, in all seasons, to take loved ones from us, but that must only serve to strengthen our resolve that life is indeed precious and Living Matters.

This is Life Café...

With some Christmas reading from our Newsletter...

The (mis)Trust that is consulting its legal advisers (NHSLA) about May's case has stopped funding for a treatment for May's daughter and our Christmas is fraught with uncertainty...

But we will not surrender so easily to despair.

Happy Holidays Merry Christmas and God bless us everyone!

Saturday, 12 December 2015

Liverpool Care Pathway - Whether Shove Comes To Shovel, It's Still A Spade

When push comes to shove, it's still determining the cause to be the fall rather than the push.
The cult of death has taken root and become a means to define a culture.

That is Quebec today...
Liverpool Care Pathway - A 'Right' To Die?

Liverpool Care Pathway - Semantics, Semantics, Semantics
This is The College of Nurses of Quebec

This exercise guide is a collaboration of three professional colleges: Collège des médecins du Québec, Order of Nurses of Quebec and the Quebec Order of Pharmacists. It provides the standards to be followed to perform medical help to die (AMM). It is a guide for doctors and other health professionals or social services in the exercise of their practice, while respecting the spirit of the Act concerning the end of life care. This exercise guide target population major and capable people, for whom the only medical help to die is permitted by law. The document also addresses the issue of conscientious objection by health professionals in connection with the marketing authorization.
If your life has been ended by medical assistance, what goes on the death certificate....?
The Exercise Guide explains...
At the scene, the doctor must establish the décès21 finding (form DEC-101, a copy of which is for the director of civil status and the other in declaring the death) and fill out the death certificate (SP Form -3, which refers to the cause of death), for the benefit of the Institut de la statistique du Québec (ISQ) (Public Health Act, Art. 46), the coroner or medical records of the case, and Finally, the funeral director.

The doctor has to register as an immediate cause of death disease or morbid condition which justified the AMM and killed.

It is not the manner of death (cardiac arrest), but disease, trauma or complication that caused death.

The term medical assistance to die should not be included in this newsletter.

Indeed, such a statement, if known uninformed relatives could firstly go against the will of a patient wishing to keep this confidential information and, secondly, cause them harm. . .
Is the professional collegiate collaboration in denial of responsibility?

An act to take a life should surely be recorded, in part if not in whole, as the cause of death.

No, not at all. Those patients deemed dying did not have LKP put on their death certificates.

This happens as practice in the profession...

This is HSJ -

An independent investigation into the death of a three-year-old boy at Stafford Hospital in 2014 has called for a second inquest into his death and heavily criticised a “closed culture within the NHS”.

The report by consultant paediatrician Martin Farrier, released today, supported the parents of Jonnie Meek, who died at Stafford Hospital’s children’s unit last year, saying their suspicion that Jonnie died as a result of a reaction to a special milk feed was the most likely explanation for his death.

Although Dr Farrier concluded there was no evidence of a conspiracy, he added: “Throughout the story there is another narrative. It is one of convenience. The finding of pneumonia by the pathologist was convenient. It meant the professionals involved not needing to consider other issues. It was accepted by all those involved other than Jonnie’s family.”

Dr Farrier told HSJ he agreed the role of an independent medical examiner, a key recommendation from previous healthcare inquiries, could have made a positive difference.

“Two different trusts. Two different times. Neither trust had a reason to hide. Both responded in the same closed, unhelpful manner.

They are determining the cause to be the fall rather than the push.

So, what goes on the death certificate...? It goes without saying.

- Mail Online
Further considerations...

This is the National Post -

Quebec doctors will soon be given standardized kits with which to end the lives of patients seeking euthanasia — including drugs to calm the nerves and stop the breathing  — along with detailed instructions as the province prepares to usher in legalized aid in dying.

The Collège des médecins du Québec has developed a new guideline for doctors unlike any in the history of Canadian medicine: a step-by-step guide to follow before, during and after administering euthanasia to an eligible patient, including the type of drugs to be used, the dose, the injection site and what to do in the event of complications.

Bill 52 allows doctors to administer lethal injections to mentally fit patients suffering an incurable illness and in constant and unbearable physical or psychological pain. He or she must also be in an advanced state of irreversible decline and be at the end of life.

“It is clearly not euthanasia on demand,” Robert said. “It is clearly not that.”
When the genie is out of the bottle...?
- Bill 52
While the Supreme Court of Canada did not define “physician-assisted death” when it threw out the century-old Criminal Code prohibitions against the practice in February, legal experts say the court opened the door to both euthanasia and physician-assisted suicide — where the doctor writes a prescription for a life-ending overdose the patient then takes himself.

The Quebec guideline could become a model for all of Canada once the Supreme Court ruling comes into effect in February.

Modelled on a formula used in the Netherlands, the Quebec protocol calls for a three-phase approach to assisted death via lethal injection.

First, a benzodiazepine, a type of sedative, would be injected to help control anxiety and “help calm the patient,” Robert said.
This first line administration of benzodiazepines may give the objective appearance of calm which may not, subjectively, be present.

For a personal perspective, see...
No Midazolam
Benzodiazepines such as Midazolam are used in EoLC...
Liverpool Care Pathway - "No Midazolam"
Second line administration...
Next, a barbiturate drug would be injected to induce a coma. The third step would be a neuromuscular block, a derivative of curare that acts on the respiratory muscles to cause “cardiorespiratory arrest.”

The whole process, from beginning to death, “would probably take something around 15 minutes,” Robert said.

Some of the drugs are “thick,” he said, meaning they cannot be given by a “bolus” or “high-speed injection” and each require about five minutes to administer.

The guideline instructs doctors to watch for reactions, such as any allergic reactions or vomiting, and to be careful not to lose access to the vein. “If the vein is clotting, probably they have to remove the needle and find another route of entry,” Robert explained.
On the Communitarian balance sheet when the choice is there...

Recommendation will be made accordingly.
Robert said the cost of the medications “is something surely less than $100.”
Is Oregon a good place to die...?
He said the Quebec college of physicians looked abroad for guidance, including speaking with the first doctor in Oregon to prescribe a legal dose of life-ending drugs to a patient under the state’s Death with Dignity Act, which took effect nearly 20 years ago. “He told us there were some bad side effects,” Robert said.

Under the Oregon law, the life-ending medication has to be taken orally, and not injected. Patients have regurgitated the lethal drugs, or, in some early cases, “reawakened” hours, sometimes days, after swallowing them. In some cases, the time to death has taken far longer than anticipated.
Doctors, trained to preserve life, must be trained to end life.
Under the guideline, euthanasia could be performed in a hospital, a palliative care hospice or the person’s home.

“Nobody feels prepared,” Robert said. “We are exploring a new continent.”

“But we have to learn how to do this as best as possible,” he said. “There is a beginning for everything.”
Doctors must be trained to kill.

When the genie is out of the bottle then all mischief is let loose.

Blog supplemental –
Liverpool Care Pathway - Doing The Addition 
Liverpool Care Pathway - The Trailblazers

Thursday, 10 December 2015

Liverpool Care Pathway - The Most Wonderful Time Of The Year?

Some seasonal Life Café for seasoned campaigners and some thoughts on unseasonal sentiments.

What a wonderful idea: that life-saving should form part of the normal, everyday school curricula; that it should be as natural as... breathing.

MPs finally debated Teresa Pearce MP’s Bill to introduce first aid in all schools. 

Two years ago, Bolton West MP, Julie Hilling, campaigned for this and started a petition which amassed 100,000 signatures.

See -
Liverpool Care Pathway - A Life Café Poser
On Friday 20th November, the Emergency First Aid Education Bill didn’t even make it through its second reading.

“Currently only 24 per cent of schools teach first aid and almost 60 per cent of children have had no first aid training at all. Without first aid education, more young people are going to leave school in England without the skills and confidence to act if they witness someone suffering a medical emergency.”

There are band wagons aplenty and band wagons galore to sign folk up to end their lives in a nice tidy fashion but the enthusiasm is lacking to preserve life.

The DoH is avidly promoting death and dying...

The Dying Matters coalition, funded by the Department of Health and led by the NCPC, has been promoting this in schools.

“The Dying Matters book, 'Dying to Know', is a great prompt to get the conversation started.”
Dying Matters, together with the National Council for Palliative Care, believes all secondary school pupils in England should be taught about issues relating to death and dying as part of the national curriculum.
We have produced a number of resources to help teachers incorporate death, dying and bereavement into lessons.
The Lakhani Recommendations caution us in the rash use of CPR, of course. We cannot have troops of young life-savers rushing in willy-nilly and non-selectively to save lives.

The Lakhani mantra is so oft reported now.

This is the Express –
DNR notices are used to stop patients suffering needlessly when their lives are only likely to be extended for a short period.

Medical experts say 15 per cent of patients at most are brought back to life, and some suffer permanent brain damage.
And this is The Mail –
Only 10 to 15 per cent of patients are saved following attempted CPR 
Well, there’s a downer for you. Hardly worth the effort of trying.

There is the cost of living and permitting to live to consider. If so few survive who are revived and rushed off to hospital, on the Communitarian NHS balance sheet it would have been best not to have stepped in at all. You don't randomly throw the starfish back into the sea.


Liverpool Care Pathway - Back To A Way Forward 
Liverpool Care Pathway - The Bee Wee Tool

The frail elderly must be left with their dignity.

There is the issue of accessing and respecting ACDs, also.

Far too weighty matters to be left for amateur life-savers to consider.

Richard Dawkins has recommended on Twitter the killing of unborn Downs Syndrome children on the grounds that it is moral to do so.

Should troops of potential life-savers be let loose to save persons without any ethical consideration of should they proceed?

Is this a jest too far to ingest...?

- The Sun

Mencap says –

People with learning disability are more likely to have a DNR (Do Not Resuscitate) slapped in their file for this reason. It is a moral judgement on perceived 'quality of life'.

Jan Tregelles, Mencap's acting chief executive, has said this is: “A scandal of avoidable deaths on the scale of Mid-Staffs.”

That is not merely thought provoking; that is disquieting and concerning.

What a wonderful idea: that life-saving should form part of the normal, everyday school curricula; that it should be as natural as... breathing.

But there are consequences to consider far more pressing.

The NHSLA has been provided with £400m to pay for legal eagles to advise on plausible deniability...

Mail Online
Further considerations -
Liverpool Care Pathway - Making The MOLST Of Your POLST 
Liverpool Care Pathway - It's Living Matters Awareness Week!