Tuesday, 24 February 2015

Liverpool Care Pathway - Jane's Story

We continue to struggle, for struggle we must, for justice, even in the face of adversity.

Two years ago it is and May’s daughter continues her fight.

Pertinent reading -
Liverpool Care Pathway - A True Story

Liverpool Care Pathway - Responses Will Be Answered

Liverpool Care Pathway - A True Story Supplemental
As if this has not been enough to contend with, Jane has had her own personal struggle, first with CLL and now with a Meningioma.
Liverpool Care Pathway - A True Story: The Next Generation
The PHSO first said that an investigator could not be allocated because of the inundation of the work load.

The PHSO next demanded that the Trust be given one last chance to provide an acceptable response.

The PHSO then went dark for five months and did not reply to any and every request and inquiry.

The PHSO have at last sent their decision letter.

The PHSO have relied upon the testament of their clinical adviser whom they describe as "a physician and geriatrician with over 20 years’ experience".

An LCP apologist.

The PHSO has conceded in its investigation that May had capacity to make a judgement upon whether treatments should or should not proceed.

Then the Team diagnosed 'dying' and May was taken out of the loop. The appropriately groomed family were involved and the LCP went ahead.

Jane has responded to the PHSO Investigator in this manner:

Thankyou for your long-awaited response.
Before proceeding with my reply, I will make the following observations:

·         I note that you speak in the past tense that the LCP ‘was’…

Actually, the LCP continues in use but in other guises. Last year, Janet Snell @Janet_Snell was tweeting on Twitter and reporting in the Nursing Standard in her capacity as Acting Deputy Editor that "Most acute hospitals are still using the Liverpool Care Pathway."

At Wirral, for example, they are using the Wirral End of Life Care Plan and Wirral Integrated End of Life Pathway. The Control Record actually states that this is just a name change. This is available online. I reproduce a copy here – 

·      You state that you have consulted with a clinical adviser, a physician and geriatrician with over 20 years’ experience. That is not necessarily a recommendation of impartial judgement. There is a great divide of informed opinion in regard to end-of-life pathways. I am not privy to whom you have consulted nor do you reveal this information to me. I will cite as follows:

Professor Pullicino -
Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically. This determination in the LCP leads to a self-fulfilling prophecy. The personal views of the physician or other medical team members of perceived quality of life or low likelihood of a good outcome are probably central in putting a patient on the LCP.

There is no data for telling if someone is in the last hours or days of life, so the actual decision is not a scientific one. The actual decision is an intuition by the group that's making the decision. If you start to say somebody has a poor prognosis, then you make a self-fulfilling prophecy.

Dr, Philip Howard –
Patients are put on the LCP by multi-disciplinary teams rather than by physicians. This indicates management decisions supplanted medical judgements. It is a decision with an end in view. The patient is dying. Why? Because we say they are dying. Why? Because we have decided.

On the wards there has been a change in attitudes with the introduction of terminal care pathways, the most familiar of which is the Liverpool Care Pathway (LCP).

We know that prognosis is not accurate and we often get our predictions of prognosis wrong. A tool based upon prognosis is therefore dangerous as it may become a decision that a person will die. Often on such pathways triple therapy is used (with morphine, midazolam a sedative and a hyoscine which is a drug to dry secretions). This means that the patient, who may or may not be dying, is given drugs that may hasten or even cause death. This is particularly true if hydration is also withdrawn. On such a regime the patient cannot survive.

On The Big Question –
I think one of the problems with the Liverpool Care Pathway is it’s predicated on a false premise, namely that you can accurately diagnose death; you can make an accurate prognosis as to when that person is going to die, within the next few hours or days. And there’s no scientific evidence that we can do that. And I know of no calibration tools that we can use to say just how accurately we can make that prognosis. That’s the danger. Now, if you then sedate the patient, stop observations, stop interventions, and stop food and fluids, the patient must die. Whether or not they would have died anyway, they must die if you adopt that regime in full.

John Smeaton –
Doctors are being pressurized to participate in the LCP even when they feel very uncomfortable about it, being told that the LCP is national policy. Some doctors are losing control of the clinical care of their own patients.

The prognosis of imminent death may well be a self-fulfilling prophecy. The LCP's combination of narcotics and dehydration is ultimately lethal. In many cases it appears that there is a deliberate intention of hastening death

The LCP is usually applied without the knowledge or consent of the patient. The lack of assessment of mental capacity of patients and the lawful obtaining of informed consent are serious concerns.

You describe your clinical adviser as a physician and geriatrician with over 20 years’ experience. As an LCP apologist, they will have likely used and recommended use of Version 11 LCP.

Version 11 LCP was illegal* in that it did not require informed consent; the Review did not review Version 11 but focussed on the legal Version 12 which superceded it.

Significantly, Version 11 did continue in use in Northern Devon into 2013. A report to the Trust Board dated 26 November 2013 stated:

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.

Your clinical adviser, a physician and geriatrician with over 20 years’ experience and an LCP apologist, therefore engaged in criminal activity if they put in place and promoted use of Version 11 LCP.


My discussion of events leading up to the implementation of the LCP is documented and has been submitted to you. This aside, the issue does remain that the law and the Version 12 LCP does require informed consent by the patient and this did not proceed.

Discussion with the family and the multi-disciplinary team should only have proceeded in the event that my mum was not competent to make this decision herself. As I have reported to you, on the very day that implementation proceeded, capacity was demonstrated when my mum remonstrated with the examining physician not to manhandle her in the manner that he did.

You state at item 12. that the family had agreed but the decision of the patient should have taken precedent. That decision was not sought and no test of competency was made as is required.

When mum declined intervention previously in regard to the treatment offered, that decision was respected. Why, then, in the respect of intervention via the LCP, was her decision not sought likewise?

You speak of ‘best interests’ but ‘best interest’ would have required the intervention she had declined. That could not proceed, obviously, because, without her permission, that would have amounted to an assault.

Therefore, in not seeking her permission to do so and making no test of competency to give her permission to do so, enacting the LCP and putting my mum on a syringe driver for 18 hours also amounted to an assault. 

* The LCP v.11 contained no provisions for either consent or a test of competency to give consent. This DoH-promoted care pathway was therefore incompatible with UK statute, and its use UNLAWFUL across the NHS from Oct. 1st, 2007 - implementation date for LCP v.12 in 2010.

I do seek and expect the Trust to make formal apology for this assault on the person of my mother,

My dear mum did have capacity to be asked and she was not asked for her permission to proceed with what the Trust has described as a “treatment decision”.

According to Lord Dyson, “there should be a presumption in favour of patient involvement” and medical staff have a legal duty to consult and involve patients in decisions. Doctors act unlawfully in failing to do so.

Yours sincerely,

Amongst evidence provided to the Investigator is this from NHS Choices –

Consent to treatment is the principle that a person must give their permission before they receive any type of medical treatment or examination. This must be done on the basis of a preliminary explanation by a clinician.
Consent is required from a patient regardless of the intervention  from a physical examination to organ donation. 
The principle of consent is an important part of medical ethics and the international human rights law.
This is plain and clear. Consent to treatment must be sought and given.

Legal advice has been sought.

Ambulance-chasers are not interested.

Those solicitors who speak honestly will say that May's life was worthless. To pursue a case for damages, the best you may hope for is compensation in recompense for funeral expenses. 

To pursue a case for justice, you will be up against a medical establishment able to call on the full resources of the NHS Litigation Authority to fund their defence and to summon all and sundry medical witnesses to speak in their cause.

You will be in the dock to fund and prove your case.

They have only to sit back in bemused self-satisfaction and watch.

Further reading -
Liverpool Care Pathway - On Pint-sizing Perceptions of Care And The Betrayal Of Trust

Wednesday, 18 February 2015

Liverpool Care Pathway - ACD Or AED? That Is The Question.

Every life is a life worth saving.

There is no 'right' to die. Death is the terminus at which we all arrive, that is our final destination. Whichever route we take through life, mortality must claim us all.

It is the last post, into oblivion or salvation, whichever it is your faith to believe.There is no need to celebrate death nor requirement  to attend Death Café.

There is a right that suffering shall be eased.

There is a need, a requirement, to celebrate life at Life Café, for life is too precious to let slip through our fingers without a fight to save it.

So, do you pack a passport to the hereafter or a parachute to break your fall? To ACD or AED? That is the question.

Debunking the Lakhani Recommendations.

Always rush in and do all that you can. Never give in, never give in, never give in: it ain’t over till it’s over!
 What is an AED?
An automated external defibrillator or AED is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to re-establish an effective rhythm.

AEDs are designed to be simple to use for the layman, and the use of AEDs is taught in many first aid, first responder and basic life support (BLS) level CPR classes

- The Defib Centre
This is life Café...

This is St John –

Everything you wanted to know about defibrillators but were afraid to ask

Defibrillator FAQ's

Why should I have a defibrillator?- Around 60,000 people have a cardiac arrest each year outside of hospital* - It can take the emergency services several minutes to arrive - The chance of survival after cardiac arrest falls for every minute that passes without defibrillation*.

Immediate defibrillation can be the difference between a life lost and a life saved.

There are a lot of myths surrounding defibrillators and their use. Here is the truth.

Myth: I can make things worse by using a defibrillator to shock someone that doesn’t need shocking.

Fact: It's impossible to shock someone that doesn't require it. Defibrillators only administer a shock when required. 

Myth: I have to be trained to use a defibrillator. 
Fact: All our defibrillators have clear step-by-step voice prompts explaining exactly how to administer the defibrillator and CPR. However we highly recommend that you do carry out training for increased confidence.

Myth: The defibrillator might stop working and I wouldn't know about it. 
Fact: Defibrillators carry out automatic self tests. If there was a problem the defibrillator would issue a warning.

Watch our video and learn more about defibrillators
View our defibrillator and training packages

The Chokeables have already saved lives...

Pertinent reading –
Liverpool Care Pathway - ‘Hands On’ Life Café
This is The Chokeables –
21 members of the public have credited The Chokeables with saving the lives of babies and children. 
The Chokeables – a 40 second ad that demonstrates how to save a choking baby – has been viewed online by more than 5.7 million people since its launch. In each instance, the person who leapt into action said they’d learned the technique from The Chokeables video.
Everyday Heroes

Heart-warming stories of ordinary people such as these, who have used first aid to save a life, are celebrated annually in the St John Ambulance’s Everyday Heroes First Aid awards, supported by Physio-Control.

If you know someone or an organisation that deserves recognition, then you have until the 28 February 2015 to nominate them.

Take a look at our awards categories and get nominating!
St John have launched a First Responder game.

Play Rescue Run online or on Facebook...

Rescue Run 

Saturday, 14 February 2015

Liverpool Care Pathway - Reports And Reports Of Reports

This is election year... and they are all so busily picking up pointers they are actually missing the point.

When a policy model is rolled out as a national programme its effects cannot be ultimately calculated but must become compounded and, like dominoes toppling, will effect unforeseen outcomes.

In this report in The Independent, they are busily picking up pointers for the pundits to raise as campaign issues.

The dominoes are toppling but the pennies haven’t dropped...

Health officials are investigating a “statistically significant, sustained” decline in life expectancy among elderly people in some parts of England, amid warnings that cuts to social care and pressures on the NHS may be contributing to earlier deaths.

Public Health England said it was scrutinising life expectancy trends following an alert from a council in the North-west of England warning it was “likely” that in many parts of the region “older people (over 85) are no longer living longer”.

Public Health England said it was scrutinising life expectancy trends following an alert from a council in the North-west of England warning it was “likely” that in many parts of the region “older people (over 85) are no longer living longer”.

An email from Blackburn with Darwen Council’s director of public health, Dominic Harrison, sent to regional colleagues and to Public Health England, said the council had seen a “sustained reduction” in life expectancy at 85 in its area. “Actual sustained cohort reductions in life expectancy such as this are now extremely unusual,” the email says.
They have foraged some windfalls for the hustings. The Independent headlines -
Fall in life expectancy raises alarm amid fears that cuts and pressure on NHS may be to blame for earlier deaths
But the devil is in the detail:
Dr John Middleton, vice-president of the Faculty of Public Health, said that a decline in life expectancy at any age was a matter of concern and should be investigated.

“We’ve enjoyed improvements in life expectancy over many years and there’s nothing to guarantee that improvement goes on forever,” he said. “It is something that is a sentinel moment in public health terms if the trend of upward improvement does stop.”
This is nothing new. Readers of these pages will have read this here before. What is going on?

A 'decline in life expectancy' is another way of saying excess deaths.

More excess deaths...

Excess deaths: again, the Kraken wakes.

It has been reported in these pages how newspapers and political interest groups will report the news to suit their own particular perspective.

Joining up the dots, they conclude cuts but you have to join all the dots.

1,400 excess deaths at Mid Staffs...

1,600 excess deaths at Basildon and Thurrock...

United Lincolnshire plus The Dudley Group plus George Eliot plus Northern Lincolnshire and Goole plus Tameside plus Sherwood Forest plus Colchester plus Medway plus Burton plus North Cumbria plus East Lancashire plus Buckinghamshire Healthcare equals 13,000 excess deaths since 2005...

Nobody held to account, nobody disciplined...

The BBC reported –


130,000 LCP deaths a year...

How many of those 130,000 would have lived on to make up the missing numbers?

"Excess deaths". Mostly, they don't bother to do the paperwork on the LCP. Trusts have admitted they have no information. If they did the paperwork, or just did it properly, they would know. They don't know.

How many of those "excess deaths" are down to implementing the LCP?

The kissing has to stop. You can’t all continue to treat this as a political football to kick around. You can’t all keep batting back the ping-pong ball; it’s not a game you’re playing. You have enacted policies and they are taking effect. It’s as simple as that and the killing has to stop.
The New Statesman –

What does this graph tell us? It tells us that the EoLC Programme has worked; the EoLC Strategy is working; and that, for the first time since Mr. Patrick Gordon Walker’s landmark speech, the demographics are going in the ‘right’ direction.
The number of older adults is increasing 
• The absolute number of older adults and their proportion in the population is significantly increasing. From 1983–2008, the proportion of the total population aged 75 years and over in England increased by a third from 6% (2.9 million people) to 8% (4.0 million people). The population aged 75 and over is projected to increase to 7.2 million in 2033, and the number of people aged 90 and over is projected to increase from 0.4 million in 2008 to 1.2 million in 2033.(Office for National Statistics).
• Increases in the ‘oldest’ population have resulted from falling mortality rates in the second half of the 20th Century and increased birth rates at the beginning of the 20th Century (Dini & Goldring, 2008). In the UK, from 1968–2008 mortality rates declined by 51% in males and 43% in females (Office for National Statistics, 2009).
• In England, life expectancy (period expectation of life at birth) increased by over 6 years in males from 1980–82 to 2006–08, from 71.1 years to 77.7 years, and by over 4 years in females, from 77.0 years to 81.9 years (Office for National Statistics) 
National End of Life Care Intelligence Network
Mr. Patrick Gordon Walker’s landmark observations echo down the years.

There are always consequences. A programme or strategy promoted and rolled out by government will multiply those consequences. There have been "excess deaths". There are "missing" older adults. Where are those missing ninety year-olds?

Mail Online has reported a ten-fold rise in palliative care deaths –

Mail Online, citing Doc Foster, sees this as massaging the figures on the sly. It suits their editorial stance and all that LCP business has dropped out of the picture and is no longer, perhaps, newsworthy.

This is Dr Foster -
The report highlights Dr Foster’s concerns that current palliative coding encompasses a wide variety of palliative pathways. Patients admitted to hospital specifically for specialist palliative care cannot currently be distinguished from those who were admitted for treatment and whose subsequent deterioration in health led to them receiving palliative care.
Roger Taylor, of Dr Foster, explains how an elderly patient might go in to hospital with a broken hip, develop an infection and die...

Actually, Mr.Taylor, this is precisely what does happen and has been happening.

It could be a broken hip, it could be anything. Curious you should say a broken hip, though...

This is Chad -
Graham Bennett’s mum Gladys was admitted to hospital in October 2010 after falling and breaking her hip at her home at Burton Court in Bilsthorpe.
But she died later that month at King’s Mill after Graham was asked to sign forms that he now believes gave consent to put her on the Liverpool Care Pathway (LCP).
“It was never mentioned, that’s what annoys me,” said Graham (70).
“It’s taken a time to come to terms with it, even though my mum 
Downsize care by downsizing care expectations. Initiate a programme of ‘identifying’ the One Percent who statistically die via a protocol of assessment involving statistical probability and intuitive judgement and earmark them for EoLC.

This will (of course!) trawl in many who would not have formed part of that One Percent cohort. By far the greater part of medical error consists of medical misdiagnosis. There will be excess deaths...

The Route to Success documents are available here.

The route to success in end of life care - achieving quality in ambulance services28 February 2012 - National End of Life Care Programme
This guide sets out the key role and contribution of ambulance services in achieving high quality care at each step along the end of life care pathway.

Whilst highlighting the crucial role of ambulance services, the guide also acknowledges the unique set of challenges and barriers that need to be addressed and overcome. 
Good practice examples and top tips are provided throughout to make this guide a key tool not only for ambulance services, but also for other health and social care providers, professionals, managers and commissioners.
Order hard copies by email to: information@eolc.nhs.uk

The "unique set of challenges and barriers" makes pertinent reading here -
Liverpool Care Pathway - On The Final Stretch
The June 2010 Macmillan End of Life Care Newsletter shares the National End of Life Care Programme logo and is published by NHS.

From the Newsletter - "Discuss with family and friends how to get care and help at different times. Specifically advise that calling 999 is very seldom appropriate and may result in resuscitation, transfer and admission."

Everywhere, in regard to healthcare, you will hear this mantra -
Affordable, Sustainable.

Target-based CQUINS were set...

This is the End of Life Baseline Report -
End of life care is a key priority of the North West regional QIPP workstream for Demand and Threshold Management and the North West SHA in recognition that improving QIPP across the end of life care pathway will significantly support overall delivery against the £20 billion QIPP challenge by 2014/15. 
"Excess deaths" continue to be the indicator that something has happened, is happening.

The Review has slammed the use of the LCP, but still reserves some good thoughts for the LCP itself. There are other ‘last days’ pathways, though, and these are all still up and running.

As mentioned in these pages, the Welsh Collaborative Care Pathway, for instance, had a 'fundamental rewrite' and was relaunched­­­ because of 'adverse publicity'. Now, the same is happening to the LCP? These should not be looked to to replace the LCP; rather, they should be subjected to scrutiny and review themselves.

Additional reading -
Liverpool Care Pathway - Missing The Plot

Liverpool Care Pathway - When The Caring Had To Stop

Liverpool Care Pathway - The Palliative Option

Liverpool Care Pathway - What Is To Be Done...?

Liverpool Care Pathway - So What's The News?

Liverpool Care Pathway - Time To Wise Up

Liverpool Care Pathway - From “Nightingale To Nightmare”

Liverpool Care Pathway - Ten Years In The Waiting
Liverpool Care Pathway – Excess Deaths

Liverpool Care Pathway - The King Lives!

Liverpool Care Pathway - All Change!

It is determined by the physician's subjective perception of a life considered worthy of life and of a life not so adjudged worthy of life. It is to do with health care rationing and the intrusion of the Communitarian ethos into the mainstream.

It is doctors abandoning traditional ethics.

It was once unthinkable to permit an action that would cause or permit death. Today, doctors don death caps and sit in judgement of their patients worthiness to live. The right to life, the right to live, has been submerged beneath a tidal wave that demands the right to die.

For years, the British public has been softened up to accept dying as a positive life option.

The Government published its NHS National End of Life Care Program in 2008.

The NCPC has been running the EoLC programme since 2009. They have downsized care expectations.

A system has been rolled out. It is in place.

A system has been rolled out. It is working.

Excess deaths...?

Excess deaths!

The project continues, and there are reports and reports of reports.