Wednesday, 25 November 2015

Liverpool Care Pathway - New Priorities For Care

When the cuts can't be found, then the scythe must be brought to the field.

In the press release published on dot Gov last year, they discussed what the “new Priorities for Care” mean –

  • The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.
  • Sensitive communication takes place between staff and the person who is dying and those important to them.
  • The dying person, and those identified as important to them, are involved in decisions about treatment and care.
  • The people important to the dying person are listened to and their needs are respected.
  • Care is tailored to the individual and delivered with compassion – with an individual care plan in place. This priority includes the fact that a person must be supported to eat and drink as long as they wish to do so, and their comfort and dignity prioritised.
These new “Priorities for Care” are not fundamentally different from the 'Pathways' they replace except, to use the current in-vogue phrase, to portray them as ‘person centred’. It is ‘buzz words’ and spin. They are still 'diagnosing' dying.

The patient is determined - 'diagnosed' - to be dying and is then classified and referred to as 'the dying person'. The mindset is set and becomes set in stone.

The Wee Belong deliberations proceeded and the Leadership Alliance produced a Draft document published on 29 July...
Liverpool Care Pathway - Not By A Long Shot
The Final document is due out in December.

The focus of medicine and those who practice it has been subtly subverted. After 2000 years, the Hippocratic Oath is being denied respect and cast aside.

The focus of the healer is no longer to heal the sick but to first determine whether they should be healed by classifying them as part of a group.

The function of the healer was always to plunge into the deep to attempt a rescue. The focus was always to try, however futile the circumstance.

It is a dangerous perspective which classifies the patient to determine not treatment but non-treatment.

It is the arrogance of the arrogant.

Lacking in all humility are they who propose that treatment is determined not by the nature of the ailment but by a determination that their patient is dying. To make such an assumption already predetermines the outcome.

Dying is a positive life choice. Let's talk about it...

Whether on ‘Pathway’ or ‘Priority for Care’, basing treatment decisions upon prognosis is unreliable at best and perilous indeed.

To ask the Surprise Question (GSF/Barton Method) and ‘recognise’ that someone is in their ‘last year of life’ already loads the dice and tips the scales in decisions for treatment/non-treatment further down the line.

Discussions on ACDs will proceed, focussed on and directed by an assumption reached by an arrogance of confidence. The EPaaCCs will record this information.

Specialists may know and recognise their limitations in palliative care.

Specialists may not know but prognosis is never easy to establish.

It is harder to determine among non-cancer people who may be dying than it is among those with cancer.

The GSF has granted a false self-confidence among non-specialists who are more confident than they should be in their ability to diagnose dying. That is cause for concern.

Comments on training:
It gave us the confidence to know what we were doing was good. WE are delivering good EOLC. It has empowered staff, it is easier to appraise them and it has boosted their confidence. It has lowered hospital admission rates because staff ask questions now and see what they can do before sending someone to hospital.
See -
Liverpool Care Pathway - Nottinghamshire Going For Gold
and the role of the Facilitator:
Rebecca Proctor, Macmillan End of Life Care Facilitator at Leicester’s Hospitals added: “I have discovered that empowering staff to recognise that patients might deteriorate and die soon is key and the training we are providing is helping ensure that these staff have the skills and confidence to provide sensitive, appropriate care in these situations.”
See -
Liverpool Care Pathway - Of CQuINs, Tipping Points And QUELCAs
The role of the EoLC Facilitator has taken hold...
The clinical facilitator will use their experience and expertise to influence and change practice in wards to improve end of life care, staff confidence to identify, assess, manage and implement best practice for patients whose recovery is uncertain. This will include developing and running education and training programmes for all staff,
See -
That initial decision taken, one decision follows upon another like dominoes toppling one upon another. One decision will set others in motion, tainting them with their colour and flavour.
Our experience at the Gold Standards Framework (GSF) Centre is that still too often, GPs are only identifying patients in the final days, perhaps weeks of life, and too few non-cancer or care home patients are included. Key to this is the GSF basic three steps:
  • Identify patients likely to be in the final year, months, weeks or days of life
  • Assess their wishes and needs
  • Plan care, enabling them to live and die where they choose, and averting unwanted crises
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
This is still a process, a protocol, and a self-fulfilling prophecy because of downsized care responses and downsized care expectations.

Whether GSF or SPICT...

Yes, the SPICT has taken root south of the border, down Coventry and Warwickshire way, with CASTLE (Care And Support Towards Life's End) –

The Coventry and Warwickshire SPICT is the recommended tool to support local health and social care professionals to identify individuals who would benefit from a supportive and palliative approach to their care. Coventry and Warwickshire health and social care professionals may download this tool to use in their place of work.

Locally a unified policy and process for advance care planning has been developed through a collaborative project involving primary and secondary care, social care, the voluntary sector and commissioning supported by a coordinated approach to education and training across all health and social care settings. This local unified advance care planning process utilises the Coventry and Warwickshire SPICT to identify appropriate individuals for the local process of advance care planning.
These are non-specialist professionals across the primary and secondary care social care, and voluntary sector 'diagnosing' dying.

Further reading -
Liverpool Care Pathway - The Outsiders And The Also-rans
Liverpool Care Pathway - The Mob Are Sending In The Cleaners
And -
Liverpool Care Pathway - The Bee Wee Tool
CASTLE gives good recommendation to 'Greensleeves' which has been mentioned in these pages previously -
Liverpool Care Pathway - So, Who's Sweeping Up In The Sweepstakes?
The "Greensleeves" has been developed by the Coventry and Warwickshire Advance Care Planning Steering Group and the Coventry and Warwickshire Unified Adult DNACPR Policy Working Group to facilitate the local implementation of the unified policies for ACP and DNACPR in Coventry and Warwickshire.
Greensleaves, Yellow Folders and Hot-Pink Papers -
Liverpool Care Pathway - Making The MOLST Of Your POLST
It’s all about standing out in the crowd. You’ve been collared and tagged for EoLC.

It's all about dealing with that 'tsunami of need'.

Juggling the figures...

Communitarian prioritisation...

And managing the spending black hole.

Additional reading -
Liverpool Care Pathway - The King Lives!
Liverpool Care Pathway - Changing Minds
Liverpool Care Pathway - Do Specialists Think...?
Liverpool Care Pathway - The Dangers Of Arrogance And The Arrogance Of the Arrogant
Liverpool Care Pathway - The Three Options: A Post-modern Fairytale

No comments:

Post a Comment