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The Liverpool Care Pathway (LCP) was subject to a Review which, ostensibly, ordered it be phased out and withdrawn.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?

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