Friday, 31 July 2015

Liverpool Care Pathway - Life And Death Café

Well, well, well... It is this, then, we have come to and life is but a trifle!
Time for some tough Life (and Death) Café.

First, some real Life Café...

This is HLN.BE 

"It feels very special but I could have seen someone die. Then I really would have been broken." Robbe, speaking to HLN
An elderly couple was yesterday afternoon drowning escaped thanks to the heroic actions of two teenagers. Robbe Haems (17) and Bjorn Cuvelier (18) saw the couple with their car in the water struggling, remained cool and could not get them unharmed dry.
Life is precious; living matters. This is the stuff of Life Café.

And now, not yet something completely different, but still more Life Café...

When a man jumped from scaffolding on a four-story building in a suicide attempt, a hero police officer miraculously saved him by using his own body to cushion the fall.

This is the Metro -

This was tucked away on page 10. The header reads: Hero cop breaks suicidal man's fall.

This act of selfless, reflex heroism took place in the People's Republic of China, a place not renowned for human-rights-respecting police officers.

Officer Liang Xiao was trying to do his level best to convince the 32-year-old man dangling from the scaffolding not to jump but was ultimately unable to dissuade him. The man had his mind set and he jumped.

The man jumped. Liang acted instinctively.

Liang Xiao "lurched forward and acted as a human shield".

Liang used his own body to break the fall of the suicide jumper.

The only reason he’s alive is because of a police officer below who used his own body to break the man’s fall.

Both men survived and were taken to hospital.

This is CCTV+ on You Tube 

Police Officer Blocks Man's Suicidal Jump Fall in South China

And now some tough Life and Death Café...

This is today's Daily Mirror -

Fiona Okonkwo had been walking her dog by the canal. A young man, Jack Susianta, ran past her and jumped in the water.

Jack had apparently fled home following a row. Police officers were in pursuit.

Jack was in difficulty.

The Officers stood by. The instinct didn’t kick in.

Fiona wanted to go in and help Jack but police officers wouldn't allow her.

Onlookers stood by...
Angry Fiona claimed police stood by and watched for half an hour as Jack struggled for life before he slipped below the surface and drowned.
"He went under. I saw the bubbles where he took his last breath."
The social architects have effected a culture change. The heroic doctor no longer responds instinctively to save a life, but assesses with clinical judgement what outcomes may ensue.The Lakhani Recommendations kick in.

There has been a seismic shift in attitudes. 'Stand by' has become standing by to watch, voyeurish, and permit the unthinkable to proceed.

The Officers stood by. The instinct didn’t kick in.

And so casual do we watch another die? So casual is become our estimate of life?
"It feels very special but I could have seen someone die. Then I really would have been broken." Robbe, speaking to HLN
Further reading -
Liverpool Care Pathway - On The Final Stretch

Thursday, 16 July 2015

Liverpool Care Pathway - A Post-Modern Whodunnit

Hiding the stitches will not blind us to the vacuity. It is still the Emperor’s new clothes.

The Daily Telegraph referred to it as the Death Pathway. It is the LCP.

The Liverpool Care Pathway (LCP) was subject to a Review which, ostensibly, ordered it be phased out and withdrawn. It was not. It continues, in spirit and in form, under many names and guises.

Here, published June, is PubMed discussing the CDP –

In 2007, the Care of the Dying clinical coordinated Pathway (CDP) was adapted from the United Kingdom Liverpool Care Pathway (LCP) and implemented in a tertiary hospital in Singapore to improve care in oncology and subsequently renal patients. With concerns about its use after the Neuberger review, an audit of patients on the CDP was performed to determine if the use of such a pathway should be continued locally.

A two-year retrospective audit of CDP use was conducted. Aspects of communication, initiation of CDP, patient monitoring, medications, nutrition, and hydration were assessed.

In the 111 patient records reviewed, there were documented extent of care discussions with 94% of caregivers and 29% of patients before CDP initiation. Of the 88% of CDPs initiated within office hours, 90% fulfilled the inclusion criteria. All patients were monitored at least every eight hours.

Seventy-three patients (66%) were prescribed opioids or sedatives and subsequently monitored appropriately, albeit 56% had no documented prior discussion with caregivers regarding medication use. Indications for opioid use were documented for all patients and only one patient had documentation of excessive sedation. Oral feeding and parenteral hydration were continued in 85% and 74% of patients, respectively.
All roads, it was once said, lead to Rome. In like fashion, it may be said, all Pathways lead to death. If, having been placed on the Pathway, you die, that is only to be expected. It is the expected outcome: you have been diagnosed as dying.

The usual suspects are identified. The grooming to downsize care expectations and to refuse interventions of care proceeds.

'Joined-up' services and integration of health and social care are moving forward at a pace. James Churchill's concerns are being realised.

The parallels between UK and NZ persist.

Over here, the DoH rolled out the Pathway; in New Zealand, a National Office was established.

Likewise, the economic drivers for change -
The stimulus for change in Canterbury was a health system that was under pressure and beginning to look unsustainable.
The quest for integrated health and social care
That sounds familiar.

Peter Millard, Emeritus Professor of Geriatrics, warned of the risk that elderly people with chronic conditions and disorders might be easily dismissed as dying when that may not, indeed, be the case.

That risk is realised through the GSF 'Surprise Question' (aka The Barton Method) and the one percent lists. Care expectations are being downsized.

The LCP has been compared with euthanasia. Euthanasia is still against the law in this land.

Outline of a script for a Monty Python sketch –
Scene: An elderly woman lies in her hospital bed. An EoLC nurse is talking to two young women, the elderly woman’s granddaughters. He is telling them their grandmother is dying and discussing the funeral arrangements. He is delicately asking them to consider how they are going to break the news to their daughters. The two young women are in distress, in denial. This cannot be… 
A voice intervenes: “Ooh, aren’t you lovely?” The elderly woman continues: “You’ve got lovely eyes.” She is flirting with the EoLC nurse.
Of course, this could not really happen. It’s surreal. It’s on a par with the ‘Parrot’ sketch.

But it did happen. The elderly lady, Kathleen Vine, is pictured with her granddaughters, Helen and Alison, on BBC News Health –

It is surreal. It is bizarre. It happened.

The pathway is initiated when it is confirmed that a person is not responding to treatment and could be dying.

If Kathleen had not woken when she did, she would have perished on the Pathway. She would have died, but that's okay because that is what they diagnosed would happen and that is what people tend to do on these EoLC Pathways.

They die: that is to be expected. It is the expected outcome: they have been diagnosed as dying.

Kathleen would have died, but she was not dying. It would have been murder.

They would have got away with murder: the perfect crime. What did happen, though, is surely an act of attempted murder...

They were doing their best to convince Kathleen's granddaughters that she was going to die. Here, they're doing their level best to convince the patient he's dead...
Scene: The Dead Collector is calling for the dead to be brought out to claim his nine penn'orth. His cart is trundled through the grim streets as he calls. His bell clangs, mournful and hollow. He prods his carters on with a swing of his stick.

A Facilitator appears with another lifeless corpse to toss onto the cart.

The body, not so lifeless, retorts: "I'm not dead!"

The Facilitator insists: "Yes he is!"

A conversation ensues with the indignant corpse continuing to insist he isn't dead and the Facilitator insisting that he is or very soon will be.

The Facilitator pleads with the Dead Collector for some intervention to end the impasse.

Finally, the matter is settled. The Dead Collector grasps his goad and, with a furtive look, responds to inflict the defining blow. 
- From Monty Python and the Holy Grail. BRING OUT YOUR DEAD
- The quest for integrated health and social care
We have come a long way. The Dead Collector’s goad is replaced with a chemical cosh; the straitjacket is replaced with a chemical restraint.

Hospira manufacture infusion pumps. These have been the subject of recent Medical Device Alerts by the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA regulates medicines and medical devices in the UK.

A more recent alert has been raised by net security blogger, Billy (BK) Rios -

Monday, June 8th, 2015 
Hospira Plum A+ Infusion Pump Vulnerabilities

In May of 2014, I reported to the Department of Homeland Security (and eventually the FDA) a series of vulnerabilities affecting the PCA 3 Lifecare infusion pump made by Hospira. Over 400 days later, we have yet to see a single fix for the issues affecting the PCA 3.
Billy Rios found software codes which, if exploited, could allow an unauthorized user to interface with and interfere with the pump’s functioning. An unauthorized user with malicious intent could access the pump remotely and modify the dosage it delivers...

Faced with Hospira’s refusal to either acknowledge or investigate these flaws, this public spirited researcher took it upon himself to purchase other pumps in the Hospira product range to check them out also.

Surprise, surprise, the same or similar vulnerabilities exist.
Given there is a public blog post, Wired article, DHS advisory, and FDA safety alert discussing the issues affecting the PCA 3, combined with the fact that the software is IDENTICAL on many Hospira communication modules, I find it impossible to believe that Hospira was unaware that the PCA3 issues also affected other pumps in their product lines.
These computerised pumps can be programmed remotely through a health care facility’s Ethernet or Wireless network. What opportunities for exploitation and abuse are there when such software susceptibilities to permit operation of the driver remotely exist!

In a high tech world, where such extraordinary possibilities for high tech crime offer themselves, what plot would Hitchcock have contrived for an unscrupulous relative to connive?

This is a Post-Modern Whodunnit scenario...
Scene: It is to be a DIUPR. The Facilitator has programmed and set up the driver...

This is the 21st century; no more is it the Dead Collector’s goad shall inflict the defining blow: today, it is a chemical cosh shall see the victim off and the deed is done.
Whodunnit? Haven’t got a Cluedo!

Pertinent reading -
Liverpool Care Pathway - The Early Years

Liverpool Care Pathway - NZ: Disbanding For Rebranding? 
Liverpool Care Pathway - 'Joined Up' Services 
Liverpool Care Pathway - Recruiting And 'Transforming'! 
Liverpool Care Pathway - The Three Options: A Post-modern Fairytale
Blog Supplemental:

This letter is...
about a proposal to allow wider access to naloxone for the purpose of saving life in an emergency. This would be achieved by an amendment of the Human Use Regulations 2012.
The proposal is to make Naloxone available to injecting drug users. Naloxone is an antidote for overdose of opioids. Feedback is currently being analysed.

Administration to opioid-dependents may cause symptoms of opioid withdrawal including agitation, nausea, vomiting, a fast heart rate and sweating...

But the intention is to save life.

Why is Naloxone not also made available in ‘Just in Case’ boxes?

What if an inadvertent overdose should occur?

Wednesday, 8 July 2015

Liverpool Care Pathway - Second Class Delivery

Is this a blind date enough to send you on a blinder...?

Many years ago, when Royal Mail first introduced a two tier delivery service, it happened that this came up as a topic of conversation with an American cousin. This cousin had the acquaintance of a USPS delivery worker who had commented to her that it was a sure fire thing that Royal Mail had made a bad decision. The service would suffer he said because that was exactly what had happened with USPS.

Looking back, who can say that isn’t so?

There is now a First Class (999) and a Second Class (111) emergency number.

Further reading -
Liverpool Care Pathway - 111, EPaCCs And The 999 Downgrade 
Liverpool Care Pathway - On The Final Stretch
A target-driven approach has been delivered for some years. A lone paramedic may be sent out in place of an ambulance to achieve a faster response time.

In January of this year, NHS England further downgraded the First Class delivery. Pilot schemes were launched giving 999 call handlers an extra two minutes to decide on whether to send out an ambulance.

Time is crucial. The imperative, however, is always the target and the prioritised use of finite resources, not the patient.

Two minutes lost on the First Class delivery. Precious time wasted on the Second Class delivery.

Expecting someone who may not, and most likely does not, possess that knowledge to determine how much of an emergency is an emergency to make the call which service to use is erring on the side of irresponsibility.

The decision is yours and it really could be a bit of a blind date.

The Telegraph reports -

The computer system used by staff to assess callers can refuse to send an ambulance even if a patient has symptoms of a heart attack. Our reporter, working at the telephone service in Oxfordshire, was unable to send a crew to a man suffering from chest pains, because he could not be sure about the cause of his symptoms.
Call handlers were told that when ambulances are “stacked” due to a backlog of requests, emergency crews should not be dispatched without the specific approval of a clinician unless the patient was having a stroke or heart attack. On one occasion when ambulances were “stacked” a senior staff member warned: “People are having heart attacks, they’re not breathing, they’re not getting ambulances.”

The reporter’s mentor was recorded on video admitting: “As horrible as it sounds, one way or another everyone in this room has killed someone indirectly because of what we’ve done…”
More than 96% of the population have an SCR and it is already being successfully used in many settings across the NHS, such as A&E departments, hospital pharmacies, NHS 111 and GP out of hours services and walk in centres. [HSCIC (Health and Social Care Information Centre)]

The HSCIC has responsibility for collecting data from across the health and social care system.

HSCIC has been quietly collecting and storing a broad cross-spectrum of information ever since it was set up in April last year.

In new plans announced 23 June, Community Pharmacists across England will also be given access to the Summary Care Record (SCR).

As 'horrible as it sounds', provision of access to records of patients who have downsized care options in place to call handlers may result in prioritisation to a DIUPR (Death in Usual Place of Residence) rather than an 'inappropriate' hospitalisation against the patients recorded 'wishes'.

"You can get people to say 'no' to almost anything if you ask it in a certain way."

So that's the way the grooming works...

Additional reading -
Liverpool Care Pathway - It Cast Its Shadow Long
Opting out of SCR does not opt out of

Wednesday, 1 July 2015

Liverpool Care Pathway - The Right To Cease To Be

A spanner in the works, a spoke in the wheel or a just a speed hump in the road?

They say it so often happens in threes...

The dominoes have tumbled.

In Canada, the Supreme Court struck down the country’s 1993 ban on assisted suicide.
Liverpool Care Pathway - A 'Right' To Die?
In South Africa, Judge Hans Fabricius decided to grant the right to die.
Liverpool Care Pathway - A Dying Scandal
Now, Radio New Zealand News reports...

A High Court judge has rejected Wellington woman Lecretia Seales' fight to die on her terms.
The legal team for the Wellington lawyer sought clarification in the High Court at Wellington on whether it would be an offence under the Crimes Act for her doctor to be able to help her die, and whether a ban on assisted dying contravened her human rights under the Bill of Rights Act.

But Justice Collins today rejected that.

"I am unable to issue any of the declarations sought by Ms Seales," he said in his finding.

"Although Ms Seales has not obtained the outcomes she sought, she has selflessly provided a forum to clarify important aspects of New Zealand law.

"The complex legal, philosophical, moral and clinical issues raised by Ms Seales' proceedings can only be addressed by Parliament passing legislation to amend the effect of the Crimes Act."
Did the domino fail to topple?

It has fell with an almighty rap on Parliament's door.

Justice Collins says Ms. Seales has provided a forum for debate. Her name will be used as a cudgel to pound on Parliament's door.

Taking up the cudgels for the killing society, an editorial leader from The Economist - 
IT IS easy to forget that adultery was a crime in Spain until 1978; or that in America, where gay marriage is allowed by 37 states and may soon be extended to all others by the Supreme Court, the last anti-sodomy law was struck down only in 2003. Yet, although most Western governments no longer try to dictate how consenting adults have sex, the state still stands in the way of their choices about death. An increasing number of people—and this newspaper—believe that is wrong.

The argument is over the right to die with a doctor’s help at the time and in the manner of your own choosing. As yet only a handful of European countries, Colombia and five American states allow some form of doctor-assisted dying. But draft bills, ballot initiatives and court cases are progressing in 20 more states and several other countries (see article). In Canada the Supreme Court recently struck down a ban on helping patients to die; its ruling will take effect next year. In the coming months bills will go before parliaments in Britain and Germany.
The natural urge to intervene and to jump into the breach, to provide assistance and to draw back from the brink, is being remodelled by the social architects. To stand back, voyeur-like, and quietly observe in perverse fascination or urge on and encourage...?

Surely not, but this is a clinical 'Brave New World'. We may be induced into this life; so, why should we not be induced out of it?

When someone can’t be bothered to live any more, Society will no longer be bothered to rush to the fore with a reason to be but will be happier to provide the reason and the means to cease to be.

Far safer and less mental trauma for all concerned.

A controlled conveyor belt into oblivion.

It is also the cheaper more logical option in an environment of limited and finite resources and when society cannot or does not want to maintain that life.

The Economist argues the 'right' to die.

The European Convention on Human rights was drafted in the wake of the horrors of the Second World War.

Foremost in the minds of those who compiled it was to enshrine some legal protection for the right of citizens to life and liberty. It is doubtful that it was ever envisaged that the convention would be used to demand the right to die.

A 'right' is normally the right to have something which you do not already have, which justice demands that you should have; which you have but which may be taken away from you. These are positive rights. What is being demanded is a negative right; it is the right not to have something.

Doctors have traditionally defended the right to life. The Hippocratic Oath is about protecting life. Is the familiar doctor-patient relationship to be thrown out with the bathwater? What role, then, for the attending physician?

The messy Assisted Suicide Bill that went before the Scottish Parliament recommended the role of a licensed Facilitator to execute the death...

To allow for a "safe and careful execution of the (assisted) suicide"

Now, the Netherlands is playing ‘catch up’ with Belgium.

This is Bioetica -
“We feel that an arbitrary age limit such as 12 should be changed,” said Professor Eduard Verhagen, of Groningen University, a long-time champion of euthanasia for children. “Each child's ability to ask to die should be evaluated on a case-by-case basis.”

Belgium has already removed the age limit on euthanasia and the Netherlands is lagging behind. Under the current rules, children between 12 and 16 must have parental approval, while euthanasia is banned for those under 12 – except for children under 12 months, who can be euthanased involuntarily.
Laura is someone who can’t be bothered to live any more...

A report in De Morgen 
She has good friends, loves good coffee and theatre. And she wants to die. Ever since childhood Laura (24) has felt: "Life, that's not for me." 
This summer, euthanasia will proceed to end her life full of inner conflict, depression and self-destruction.
 I met the West Flemish Laura at the presentation of the book 'Libera me' euthanasia for psychological reasons. Writer Lieve Thienpont is one of the psychiatrists who gave Laura a positive opinion for euthanasia. As Laura speaks about it, I see a calm, deliberate, confident young woman. That she, meanwhile, is busy planning her death seems unreal.

Laura is to cease to be. Quite simply, this is ‘rational suicide’.

Who will it be who executes this assisted suicide? Margo's Assisted Suicide Bill promoted the role of facilitator or assister who...
would have no personal connection to the person being assisted, unlike friends and family members who may feel motivated to try to interfere with the autonomous decision of the individual (either by encouraging someone to commit suicide or by attempting to dissuade them from doing so).
In writing risk assessments, prior suicide attempts must be taken account of. However, in a world where suicide is considered a valid option for the client to address their mental health, where does this leave the assessor?

In a long article in The New Yorker, Rachel Aviv discusses death as treatment.

Godelieva De Troyer’s condition was non-terminal but enduring. What help she sought would provide treatment but no solution. Then she met Wim Distelmans who provided her with the final solution.
Wim Distelmans, an oncologist and a professor of palliative medicine at the Free University of Brussels. Distelmans was one of the leading proponents of a 2002 law in Belgium that permits euthanasia for patients who have an incurable illness that causes them unbearable physical or mental suffering. Since then, he has euthanized more than a hundred patients. Distelmans, who wears leather coats and boots and artfully tossed scarves, has become a celebrity in Belgium for promoting a dignified death as a human right, a “tremendous liberation,” and he gives talks at cultural centers, hospitals, and schools around the country.
Godelieva left a family behind her...
In his mother’s living room, Tom found an article about Distelmans in De Morgen, a leading Flemish newspaper, which featured a large photograph of him sitting on a bed, wearing jeans, a patterned shirt, and a silver bangle bracelet. The reporter described Distelmans as a doctor who “cannot stand injustice.” Distelmans spoke about his disdain for doctors who assume that they know what their patients need, and told the reporter that the “euthanasia law has such a symbolic value. People have a voice.” 
Tom also discovered a booklet, produced by LEIF (Life End Information Forum), an organization founded by Distelmans, that outlined the medical and legal options available to people who are dying or want to die. On the final page, the authors introduced an excerpt from “Utopia,” by Thomas More, who describes a world in which “officially sanctioned euthanasia is regarded as an honorable death.” In More’s ideal society, government officials and priests visit suffering invalids and say, “Why don’t you break out and escape to a better world?”

Will the social architects, hard at their work, produce a Werther Effect? May we expect a mass suicide to enter this “better world”? Have we not seen this already in the manifestation of cult suicides?

What value, then, is human life? If life is a such a tedious matter, why bring children into this world to endure it? By these rationale, should we all not seek out that final EXIT?

Additional reading -
Liverpool Care Pathway - A New Hope...?
Liverpool Care Pathway - And "Rational" Suicide 
Liverpool Care Pathway - The Pro-Death Advocacy 
Liverpool Care Pathway - The Werther Defectives