Sunday, 1 March 2015

Liverpool Care Pathway - Twenty Four

Jack's back...
But who's watching ours?

The APM (Association for Palliative Medicine) has recently published a press release to the effect that it is opposed to physician assisted suicide -

Doctors who care for dying people are unwilling to participate in physician assisted suicide

A survey of members of the Association for Palliative Medicine (APM) published today confirms continued opposition to physician assisted suicide.
Do you think that the law in the UK should be amended to allow Assisted Suicide as proposed in Lord Falconer's bill?

Yes                            12%                  43

No                              82%                  298

Don't Know                 6%                    24

With the programme to limit life so well advanced and advancing it is all superfluous in any case except in setting us out on the slippery slope of universal provision of the means of EXIT.

In June last year, the APM held a North West Conference on EoLC and the law -
End of life care and the law

Healthcare professionals of all levels need to have an understanding of the legal and ethical framework that surrounds the care and treatment of patients who are nearing the end of their lives.

This understanding should include the use of DNACPR orders, the implications of withholding and withdrawing life sustaining treatment, advance decisions and other relevant sections of the Mental Capacity Act.
This has become pertinent following the illegal application of the Version 11 LCP which evaded oversight by the Review.

The Review recommended the phasing out of the LCP. This has not happened as we all well know. There have been name changes, and scions abound; LCP apologists everywhere speak out in its defence. The Review was, after all, not a review of the LCP but of how the LCP was put into practice.

The Chairman has taken a back seat and others have come to the fore. A 'Gang of Four' and more have seized the moment to make their mark, not 
to usurp the Helmsman's role but to compliment it.

The South London CLAHRC (Collaboration for Leadership in Applied Health Research and Care) is the only CLAHRC with a dedicated palliative and End of Life Care workstream.

A launch event was held just a year ago, on Thursday 27 February 2014 at the Cicely Saunders Institute, King's College in London.

This is You Tube -

And here is Irene Higginson taking the pulpit...

NIHR CLAHRC South London -palliative and end of life care, Prof Higginson

Published on Jun 2, 2014

NIHR CLAHRC South London -- palliative and end of life care, Professor Irene Higginson, Scientific Director, Cicely Saunders International, NIHR Senior Investigator

NIHR CLAHRC South London palliative and end of life care research -- launch event held on Thursday 27 February 2014 at the Cicely Saunders Institute, King's College London

Cicely Saunders Institute is delighted to announce the launch of our theme on palliative and end of life care, as part of the new South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC), awarded by the National Institute for Health Research (NIHR). We are pleased to be a part of this successful peer viewed CLAHRC.

We are hoping the CLAHRC, whose formal funding purpose is mainly London South, will enable us to also develop a collaborative approach to palliative and end of life care across the whole of London, the South East and beyond.
Our planned future programme on this palliative and end of life care theme includes: analysis of routine data and outcomes, and our new Outcome Assessment Complexity Collaborative (OACC) which seeks to embed routine outcome measures into routine clinical practice to improve care. As part of the CLAHRC we will be analysing routine data to investigate geographical inequalities in accessibility and place of death.

The focus, as it always was, is economic. The focus is in reducing that  higher economic cost.

‘Most people’ would prefer not to die just yet thankyou very much.

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 that they're thinking of checking out anytime soon or they want the doc to give up on them.

They state the obvious and make an issue of it. Other than in time of war, it would be an expectation that the majority of deaths would be among the elder portion of the population. We are mortal beings; our life-span is finite.

The Gomes Higginson graph shows up a significant feature. Births plummet following circa 1967, the year of the Abortion Act. This succinctly illustrates how Government policy, rolled out, does have and can have devastating outcomes and consequences.

The Gomes Higginson graph drawn up in 2008, is already out of sync with the outcomes and consequences of the roll out of the LCP and other EoL Pathways. “Where are the missing 90-year-olds...?”
Liverpool Care Pathway - Reports And Reports Of Reports
When a policy model is rolled out as a national programme its effects cannot be ultimately calculated but will become compounded and, like dominoes toppling, will effect unforeseen outcomes and consequences.
Cicely Saunders Institute:

King's College London, Cicely Saunders institute, Department of Palliative Care, Policy and Rehabilitation offers Postgraduate Certificate, Postgraduate Diploma, MSc and PhD in palliative care:
Contacts:Michaela EcclesTel: +44 207 848 5435Email:

GPs have been tasked with rounding up their one per cent.

Irene has her focus on the one in three...
Almost one in three patients in hospital at any given time is likely to die within 12 months.
- University of Glasgow
A new study led by an academic from the University of Glasgow examined the age, health and treatment of more than 10,000 patients in 25 hospitals across Scotland, identified on a single day.
The findings of the survey, the first of its kind in the world, showed that with 28.8% of patients likely to die within 12 months of a hospital admission, more work needs to be done to recognise when patients are nearing the end of their lives and their potential need for palliative care.
- University of Glasgow
Our census identified 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010 (we excluded cottage and community hospitals and long stay facilities).  We found that 3,098 (28.8%) patients died during the one year follow up period: 2.9% by 7 days, 8.9% by 30 days, 16.0% by 3 months, 21.2% by 6 months, 25.5% by 9 months and 28.8% by 12 months. 
The likelihood of dying rose steeply with age and was three times higher at one year for patients aged 85 and over, compared to those who were under 60.  Men were more likely to die than women. 
A striking finding was that almost one in ten patients (9.3%) of patients died during the  admission on which we recorded them – and this accounted for 32.3% of all the deaths within the 12 month follow-up period.
The 28.8% found by the study correlates rather too well with the 29% on the Pathway (equivalent to 130,000 deaths a year). That is just too fanciful to consider!

At the launch event, the Amber bunch were in attendance lapping up the palliative nectar. They have gone global with Amber, launching in Oz, and caused a stir recently when their success rang alarm bells that Guys was actually falsifying its EoLC figures...
Liverpool Care Pathway - Missing The Plot
Most common chronic diseases have an uncertain prognosis which makes assessment difficult.

Depending on the structure and dynamics of the so-called 'multi-disciplinary' team, a wrong diagnosis may be readily confirmed and the error compounded. The perception of dying - at once erroneous and foolhardy though it may well be - by its certain outcome, death, will actually be taken as confirmation of the diagnosis.

The Collaboration for Leadership in Applied Health Research and Care [CLAHRC] South London is investigating the best way to make tried and tested treatments and services routinely available. University-based researchers, health professionals, patients and service users are working together to make this happen. • The collaborating organisations are Guy's and St Thomas' NHS Foundation Trust, Health Innovation Network [the NHS England-funded academic health science network in south London], King's College Hospital NHS Foundation Trust, King's College London, King's Health Partners, St George's Healthcare NHS Trust, St George's, University of London and South London and Maudsley NHS Foundation Trust. • The work of the CLAHRC South London is funded for five years [from 1 January 2014] by the National Institute for Health Research, collaborating organisations and local charities. It is 'hosted' by King's College Hospital NHS Foundation Trust. • The CLAHRC is also working closely with GPs, local authorities [responsible for public health] and commissioners of health services in south London.
The DoH (Department of Health) funds research through the NIHR (National Institute for Health Research). The South London CLAHRC has won NIHR funding from January 2014 for a five year period.

In bidding for funding to the NIHR, the soundbites are all important.

It is not what is said as much as how it is said, how it is all put together to win over and obtain the funding.

Dr. John Dorling advises involvement of a CTU...

No, no...

- What makes a good NIHR application?

That's a Clinical Trials Unit...

not a Jack Bauer CTU Counter Terrorist Unit!

Just a 24 hour...

Was that what Jack was doing over here in London last year…?

The issue becomes an issue when, as Mr. Patrick Gordon Walker highlighted in his landmark speech, that elder portion of the population becomes of demographic significance. Money must be saved and there is money to be made in saving that money.

- What we know now 2013
12.4 A study that examined the use of health and social care services for over 73,000 people in the last 12 months of their lives found the total social care and hospital costs to be £10,130 per person in the final year of life. With over 465,000 deaths nationally in England in 2008 this represents £4.7bn in final-year hospital and social care costs. (Does not include primary care, community care and prescribing costs). 
12.5 Hospital costs in the last year of life equated to £6,644 per person and social care costs at £3,486 per person.

The LCP demonstrates its head start...
Hospital implementation of the five enablers in November 2012 fully implemented, in process of implementing or have defined plans to implement

Overall Aim: Establishing a palliative and end of life care collaborative across South London

Theme Lead: Professor Irene J Higginson
To establish a science-based, inclusive, focused, well managed collaborative in Palliative and End of Life Care (PEoLC) that leads and conducts applied health research relevant across the NHS, and that translates research findings to improve outcomes for patients and their families. This incorporates patient, family and public engagement.
Project 1 
Geographical Accessibility to healthcare facilities and place of death in South London Stream 
Lead: Dr Gao WeiResearch Assistants: Joanna M Davies and Clare PearsonThis workstream draws on earlier work from the GUIDECare project, using routine data resources to understand more about variation in place of death. A key aim is to map the geographical location of healthcare services in South London and visualise how variation in place of death is related to the location of services. The outputs will be useful for service planning and commissioning, optimising resources, for understanding more about factors associated with place of death and how services can be configured to meet people’s needs and preferences. One of the main datasets we will use is the Death Registration Data from the Office for National Statistics which contains records on all deaths that happen in England. We will also link together data from various different sources to produce a complete picture of palliative and end of life care (PEoLC) services in South London.
Project 2
To agree and implement a common set of measures to capture patient needs and outcomes in palliative and end of life care
Stream Lead: Dr Fliss MurtaghThe outcome and data collection work stream aims to measure, demonstrate and improve care through the use of outcome measures. This work stream will use individual (routinely collected) clinical data and aggregated (e.g. facility, workforce, service-level) data to improve our understanding of population needs and outcomes, support evaluation of interventions and benchmarking, build capacity in staff and services, and enhance patient outcomes and experiences.

Cross-cutting stream across Projects 1 and 2: Patient and public involvement
Stream Lead: Dr Barbara DavesonTo establish a science-based, inclusive patient and public involvement model, which produces quality research outputs and adds value to projects one and two - helping to lead patient and public involvement in palliative and end-of-life care applied health research relevant across the NHS, ensuring research relevance and quality.
They’re eyeing our backs with a £9 million grant.
- About the CLAHRC South London

Funding and operational arrangements
The work of the CLAHRC South London is supported by a £9 million grant from the National Institute for Health Research (NIHR), to be spent over a five-year period, starting 1 January 2014, plus ‘matched’ funding from local organisations. Much of that matched funding has been promised in time from staff at collaborating organisations who will work on CLAHRC projects, and the Health Innovation Network has contributed some money that will pay for specific posts.
Money must be saved and there is money to be made in saving that money...

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