Sunday, 27 December 2015

Liverpool Care Pathway - End Of Year Review Of Outcomes

Nothing changes but the name; nothing changes but it stays the same.

In July, NICE published its draft guideline for consultation with stakeholders...
Liverpool Care Pathway - Not By A Long Shot
This took the same line as the Neuberger Review:
These are not necessarily direct consequences of following the LCP approach, rather a poor implementation of it and without ensuring adequate training and supervision of frontline staff.
It wasn't the Pathway; it was the implementation of the Pathway.

It is worth commenting that, if the training was inadequate, the person in charge of the training holds some grave (grave being the operative word) responsibility for that.

Macmillan Newsletter describes an e-Learning package for End of Life Care and the Liverpool Care Pathway -
"Nearly all health and social care staff need training of some sort in end of life care. A new e-learning package aims to offer just that"

In the context of End of Life training, it is surely inappropriate and, quite simply, offensive to describe the training offered as being "easy, fun and free". It is so described in the Macmillan Newsletter.

Dr. Bee Wee, National Clinical Lead for e-ELCA, certainly seems to be 'having fun' in this photo-shoot picture from the Newsletter.

"Easy, fun and free" is almost as crass as that infamous 'Mission Impossible' slide from Carmel Wiseman at Bolton Medical Learning Zone.

Dr. Bee Wee, as President of the Association for Palliative Medicine, was responsible for the catastrophic programme of training. See -
Liverpool Care Pathway - Lost Upon A Pathway
Following consultation, a final document was pencilled in for December...
Liverpool Care Pathway - New Priorities For Care
NICE guideline

the final document, 'Care of dying adults in the last days of life', was published on the 16th December –
Recognising dying

Recognising dying can be challenging for health and care professionals. There is often uncertainty about how long a person has left to live and the signs that suggest that someone is dying are complex and subtle.


Some health and care professionals are uncomfortable discussing how long someone has left to live, and sometimes do not have the skills and confidence to give difficult news or talk about the dying process. Adequate training and continued support is important to help health and care professionals to communicate sensitively and effectively.

Shared decision-making

Effective shared decision-making can help to ensure that people get the right care in the last days of their life. Health and care professionals can help to achieve this if they have the right communication skills, and have a good rapport with the dying person and those important to them.
This is really same old same old. What is offered, priority or pathway, is still a protocol.

The document asks:
What can health and care professionals do to help?
...and references the same e-Learning training programmes at e-ELCA -
Use training programmes such as e-Learning for Healthcare's e-ELCA to improve their knowledge and skills.
Whilst recognising the fallibility of diagnosis, the document makes reference to the ‘dying person’ throughout.

By describing the person as a dying person you have already classified that person and taken that first step to downsize their care options.

Here is truth: How may you tell when will be the moment of death? God alone knows!

Here is Mail Online –
Doctors are still following the abolished Liverpool Care Pathway because they think they know best when it comes to caring for dying patients, the health watchdog has warned.
This same ‘health watchdog’ recommended the LCP as best practice.
In the worst cases the LCP, which was introduced in the 1990s, saw patients denied sustenance for several days before their deaths, while others were written off even though they could have recovered.
A medical holocaust has proceeded and no-one is to be brought to account.
The Government ordered an independent review in 2012 which recommended that hospitals abolish the practice by July 2014.
Denise Charlesworth-Smith took the case of her father, murdered on the LCP, to the highest in the land and only out of that came the Neuberger Review into how the LCP was used in practice.
Earlier this year nurses and other experts gave evidence to MPs on the health select committee that the pathway was still being used by hospitals ‘under a different name’.
We know all about The Wirral et al...
The Wirrall
They included Adrienne Betteley, an expert in end-of-life care for the cancer charity Macmillan, who said: ‘There are areas that I know that have almost tweaked the original document and called it something else – and that is very concerning.
Really Adrienne, Macmillan was among those which promoted, supported and vociferously defended the LCP even in the face of massive evidence of the medical holocaust that was proceeding and which was dismissed as anecdote in parliament...
Liverpool Care Pathway - "Anecdotal And Without Substance"
In response to those who can't kick the habit and continue to use the LCP and its scions, Professor Ahmedzai says, “Woe betide them.”


Nick Cartwright writes in the Huffington Post –

There were undeniably bad decisions; there will undoubtedly be more in future. However, ditching the LCP is akin to accepting the excuses of the bad workman who always blames his tools and redesigning his tools for him. Odder still would be to accept the bad workman's excuses and rename his tools rather than redesigning them, yet NICE are retaining many of the core principles of the LCP.

My point is that more rules, or different rules, are rarely the answer.

Mr. Cartwright, the problem was, quite simply, the rules.

And is that your summation of the deaths by LCP, that there were undeniably bad decisions and there will undoubtedly be more in future...?

God help us...

GP's are still marking the cards of their one percent to downsize care options.
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
The NCPC, which also rabidly promoted the LCP, also now backs the NICE guidelines which, as Mr. Cartwright points out, are not fundamentally different from those of the LCP.

The Government published its NHS National End of Life Care Program in 2008 and invited the NCPC to groom the British public into accepting the idea of dying as a positive life choice. Out of this was formed the Dying Matters Coalition and the Death Cafés. The NCPC led the Coalition from 2009.

The Department of Health committed to investing 286 million pounds over the two years to 2011 to support implementation of its National End of Life Care Strategy and implementation of the LCP.

Doctors do actually use flow charts in diagnostic procedure. It is the fallibility of the flow chart that, like that of the machine, it is a linear, yes-no thought process with no what-if.

In getting the machine to think like the human, humans are beginning to think like machines.

Intuitive/iterative programming is making strides but our health professionals are still stuck in the mud of linear flowcharts. Once your card is marked, the options further down the line are already prejudiced.

Last word -
“You don’t need a lot of intensive scientific training to encourage people to show respect and give compassionate care,” he said. [Prof Ahmedzai]

But Prof Patrick Pullicino, one of the first medics to raise concerns about the Liverpool Care Pathway, said the new advice was as bad as the approach it replaces.

He criticised the attempt in the guidance to identify “signs” that a person might be dying, saying once patients were “diagnosed” as facing death it inevitably meant their treatment was changed and their death more likely.
 The Telegraphl

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