Liverpool Care Pathway - The Hippocratic Oath Has Been Suspended

Mr. Hunt has formally suspended the Hippocratic Oath. There are many doctors who think it 'cool' and think themselves 'cool' who would say, So what...?

Dr. Christian Jessen tweeted -

Robert Francis, Chairman of the Mid-Staffs Inquiry, said that a top priority was for the NHS constitution to be rewritten to put patients first and that everything done by the NHS should be informed by this ethos.

He recommended that the Health Secretary should also insist that NHS staff “put patients before themselves”.

These two recommendations enshrined in the NHS constitution would have enshrined the precepts of the Hippocratic Oath within the NHS.

The Telegraph reports -

FOOTNOTES:

Hippocratic Oath: One of the oldest binding documents in history, the Oath written by Hippocrates is still held sacred by physicians: to treat the ill to the best of one's ability, to preserve a patient's privacy, to teach the secrets of medicine to the next generation...

THE DUTIES OF A DOCTOR REGISTERED WITH THE GENERAL MEDICAL COUNCIL:“Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life.”

Liverpool Care Pathway - Still No Duty Of Candour

If this is how ministers respond to the Mid-Staffs inquiry, what hope is there for the current review of the Liverpool Care Pathway...? 

Janet Daley, in the Telegraph, says -

As Mr Foulkes points out, the hacking of telephones is already a crime and the perpetrators of this current pestilential epidemic of it, are – now that the police feel obliged to enforce existing law -  being prosecuted. No further legislation is required – or ever has been required – to put a stop to this practice. And yet, Hacked Off are invited to top level conclaves with leading members of all three major political parties and their demands for new statute are treated with the utmost seriousness.

Contrast that treatment if you will with the pressure group formed by relatives of those patients who died at Mid Staffs Hospital. The deaths of their loved ones were certainly a result of criminal acts of neglect: the most straightforward charge that could be brought against individual members of hospital staff would be criminally negligent manslaughter. That is certainly the offence with which you or I would be charged if an elderly relative died of thirst or hunger while in our care. Or, alternatively, the management of Mid Staffs Hospital Trust could be brought to trial on a charge of corporate manslaughter. If Network Rail could be prosecuted for this offence over the negligent maintenance of railway track which resulted in a fatal accident,  why should not a National Health Service management team be liable in a much more direct case of presiding over dangerous and unacceptable conditions?

Guardian

Liverpool Care Pathway - The PCRs

Netting the one percent...

"Well, here's to your 1%..."    - photo credit: commons.wikimedia.org 

The PCR (Palliative Care Register)

Most people, if asked, would express the wish to die at home. This hypothetical response to a hypothetical question is used as a reason to downsize expectation for those on the PCR.

The Communitarian concept of 'Fairness' is used also as a reason for inclusion. It all seems so reasonable. Thus is the scope of definition extended - 

Epidemiology 

Each full-time GP will have an average of about 20 patient deaths per annum. Typically, 5 will be due to cancer, 5-7 organ failure (cardiac, renal, COPD), 6-7 through dementia, frailty and decline and 1-2 sudden deaths.^[6] Palliative care will be appropriate to many more patients in their care (the average GP has 40 patients with cancer, for example) at any stage in the disease and treatment path from pre-diagnosis to bereavement or survivor support. 

Palliative care provision remains uneven in the UK. The 2004 House of Commons Health Committee's 'Inquiry into Palliative Care in England' found: 

• Gross inequality of access to hospice and other specialist palliative care services by diagnosis (95% went to people with cancer).

• National Institute for Health and Clinical Excellence (NICE) guidance on 'Supportive and Palliative Care for Adults with Cancer'^[7] should be fully implemented and its underlying principles should be extended to develop palliative care for patients suffering other life-threatening conditions.      (Palliative Care)

A palliative care document (PALLIATIVE CARE DES 2012 - 13) says -

AIMS

Level 1 activity

• Encourage the identification of patients approaching the end of their lives who have, or are likely to have, complicated or complex needs

• Encourage the formation of an Advanced / Anticipatory Care Plan (ACP), ideally with the involvement of the patient and carers

• Encourage the transfer of useful clinical information to OOH services

Level 2 activity·   

o       Encourage reflection on expected deaths
o        Including patients dying with cancer, non-malignant disease and with/without ePCS
o        Also encourages reflection on patients with/without DNACPR, on/not on PC DES register, preferred place of care and use of end of life care pathway (LCP or equivalent)
·         Encourage the use of the Liverpool Care Pathway (LCP) in the management of the last few days of life

This is all airy-fairy. 'Have or likely to have'. With and without ePCS (electronic Palliative Care Summary'.

The Palliative Care DES (Directed Enhanced Service) provides financial reward for the GP practice -

DES PAYMENT

Level 1 activity·        

·        Payment is per patient and is not capped.
·         Data will be extracted automatically by use of the ePCS
·         There is no longer payment for use of the LCP for the last few days of life
Level 2 activity·        

·        A standardised report must be completed detailing reflective practice.
·         This will involve malignant/non-malignant, use of ePCS, expected/unexpected death, preferred place of care, use of LCP amongst other aspects

The Communitarian concept of 'Fairness' steps in again -

·         It is also important that practices attempt to ensure that patients, particularly those with non-malignant disease, are not overlooked and therefore it may be useful to construct a second, less formal, register of patients who are possible candidates for future inclusion in the PCR

A document from NHS Lothian in Scotland (PALLIATIVE CARE A Brief Intervention) supplies a flow chart -


The document advises the GP to register the patient on the ePCS and obtain consent after -

The Palliative Care DES
• Decide who should be on it (see ACP / ePCS)
• Add data via ePCS template
• Then
   –  Obtain consent
   –  Add palliative care review date
• THEN
   –  Add to Palliative Care register

The Palliative Care DES
• Patient cohort – patients on palliative care register
• 2011 – 12
   • ACP & transfer to OOH medical service within 2 weeks
   • Payment based on percentage achieved
   • Capped c6.5/1000 patients
   • Payment (token!) for using LCP
• 2012 – 13
   • ACP & transfer to OOH medical service within 2 weeks
   • Payment per patient
   • No cap
   • No LCP payment
   • Level 2 payment for SEA

[glossary of terms: • Anticipatory Care Planning (ACP). – Including 'My Thinking Ahead & Making Plans'. • electronic Palliative Care Summary (ePCS). • Palliative Care DES (Directed Enhanced Service). • Significant Event Analysis (SEA)]

Liverpool Care Pathway - "To Free Up Hospital Beds"

The unthinkable can become thinkable.
 The Mail

CNN reports -

That the head of a hospital facility and seven other doctors and nurses are accused of killing patients to free up hospital beds. This is in the south-east city of Curitiba, Brazil.

Virginia Helena Soares de Souza, head of the facility, has pleaded not guilty. Elias Mattar Assad, lawyer, has said she will prove that her orders in the ICU were backed and justified by medical literature.

"Well, we got rid of two today, so let's put that other one off until tomorrow..."

Soarez de Souza acted against the wishes of patients and their families. Her motive, according to wire taps, was to free up hospital beds.

Anesthetics, sedatives and painkillers were used, including withdrawal of oxygen supply.

De Souza was arrested in February, but was later released until trial. Her court appearance Wednesday is part of mandated monthly appearances to avoid going back to jail.

Investigators say between 2006 and 2013, de Souza ordered medical professionals working under her at an intensive care unit to alter medication and oxygen levels.

In an interview with CNN affiliate TV Globo, Mario Lobato, the doctor tasked by the health ministry to investigate the case, said the number of deaths could be much higher.

He said his team is analyzing medical charts of more than 1,700 patients and interviewing more doctors.

During the seven years the incidents occurred, in cases where de Souza did not prescribe the drugs herself, she ordered other doctors to change mechanical ventilation devices, according to authorities. She allowed them access to medical records to issue prescriptions in her name, police said.

CNN affiliate TV Record reported that the investigation began a year ago. In telephone recordings made with the consent of the justice department, de Souza ordered other medical doctors and employees to shut down some ventilation devices.

Euthanasia is considered a crime in Brazil.

Marilia Brocchetto, CNN
March 28, 2013 -- Updated 1737 GMT (0137 HKT)

Over 300 deaths, avoidable deaths...


The Guardian


In the UK, it has been suggested that hospital codes have been 'doctored'...


NHS local


Hospital Standardised Mortality Ratios (HSMRs) are being "gamed"...


A 'Murky' Business


Data-chondria...

There were concerns about the Royal Bolton hospital after GPs took issue with the high numbers of sepsis cases which coincided with apparent improvements in death rates.

Computer Weekly, using data over a 17 year period, from 1996 to 2013, has demonstrated that the Mid-Staffs deaths are "about average" -

Mid-Staffs maintained and then bettered its rate death even while it bore a large increase in admissions of patients with serious illnesses.

Even so, a pie chart supplied in the Computer Weekly article demonstrates that, during the targeted period, actual deaths, 12,888, were still nearly 6% higher than the predicted 12,162.

Is there murk, murk everywhere and nothing to be seen...?

Evidence produced at the Mid-Staffs inquiry did reveal acts of gross negligence. Does the Computer World interpretation of the figures actually demonstrate a more widespread and consistent picture of unacceptable 'normality' in our hospitals...?

Janet Daley, in the Telegraph, says -

As Mr Foulkes points out, the hacking of telephones is already a crime and the perpetrators of this current pestilential epidemic of it, are – now that the police feel obliged to enforce existing law -  being prosecuted. No further legislation is required – or ever has been required – to put a stop to this practice. And yet, Hacked Off are invited to top level conclaves with leading members of all three major political parties and their demands for new statute are treated with the utmost seriousness.

Contrast that treatment if you will with the pressure group formed by relatives of those patients who died at Mid Staffs Hospital. The deaths of their loved ones were certainly a result of criminal acts of neglect: the most straightforward charge that could be brought against individual members of hospital staff would be criminally negligent manslaughter. That is certainly the offence with which you or I would be charged if an elderly relative died of thirst or hunger while in our care. Or, alternatively, the management of Mid Staffs Hospital Trust could be brought to trial on a charge of corporate manslaughter. If Network Rail could be prosecuted for this offence over the negligent maintenance of railway track which resulted in a fatal accident,  why should not a National Health Service management team be liable in a much more direct case of presiding over dangerous and unacceptable conditions?

So, in Curitiba, they're  still examining the figures, but they have brought charges.

Perhaps, everything is clearer, more black and white in Brazil.

Here, it is more murky. They've examined the figures, and, and...

Liverpool Care Pathway - What We Know Now

The Guardian Healthcare Professionals Network 

identifies an ageing population and pressures on public spending as targets for an EoLC refocus.

The author also refers to the Francis Report and NHS reform in this context. This falls in line with recent recommendations to keep the elderly out of 'dangerous hospitals'.

The focus in EoLC is necessarily going to be on economy of treatment and downsizing expectations.

In the article, authored by Dr. Phil McCarvill, Head of Policy at Marie Curie, a shift in care is recommended

"We are not calling for a mass clearance of hospital wards, but rather for a well-planned, system-wide programme to shift resources and support available in care homes, hospices and people's own homes." 

"Tens of thousands of vulnerable and elderly patients should be treated in the community, the doctors say, where they will be more safe than in hospital. 

The appeal follows the public inquiry into hundreds of avoidable deaths at Stafford Hospital." [Mail Online]

The author urges  that 'we must also increase the number of people with Advance Care Plans'.

"What we have learned over the past twelve months provides us with the evidence base required for such a shift."

This is the National End of Life Care Programme Intelligence Network and What do we know now that we didn’t know a year ago? -

9. What we know about costs of care

9.1 If all people who die in hospital stayed only a maximum of eight days, then the total estimated cost to commissioners would be lower by approximately £357m pa.

(Source: Ian Blunt Analysis of Hospital Cost data – Nuffield Trust unpublished)

9.2 The estimated total cost of acute admissions ending in death in 2010-11 was over £520m.

9.3 In England a 10% reduction in the number of hospital admissions ending in death could potentially result in a saving of £52m.
(Source: CMG42 Guide for commissioners on end of life care for adults. NICE, 2011) Quality Innovation Productivity and Prevention (QIPP) data:

9.4 The majority of people admitted as emergencies in the last of year of life have only one or two such admissions. However in the five year period between 2004 and 2008 an annual average of 83,760 people had three or more emergency hospital admissions in the last year of life, which is almost a quarter of all people with at least one such admission.

9.5 The price of an inpatient admission in the last year of life that ends in death is estimated to range from £2,352 - £3,779, with NICE estimating the cost to be £2506.

9.6 The cost of an inpatient bed day in the episode of care that ends in death is estimated to range from £200 - £425.

9.7 Whilst there is considerable difficulty in measuring the costs of community-based end of life care, it is estimated to range from £1,415 - £2,800 per person, per episode at the end of life.

9.8 Taking a midpoint of the estimated inpatient (£3,065.50) and community-based (£2,107.50) end of life care costs, there is an estimated potential net saving of £958 per person who dies in the community.

9.9 A 10% reduction in bed days for the cohort with a length of stay of more than eight bed days ending in death could yield savings of around £57m in hospital costs at £200 per bed day. However, any reduction in bed days must be based on clinical need, quality of care and individuals’ preferences. Additional costs in the community would be anticipated.
(Sources: QIPP Indicator for End of Life Care. Proposal of a new indicator, NEoLCIN, unpublished
QIPP End of Life Care. Hospital admissions in the last year of life, NEoLCIN, unpublished
QIPP Reviewing end of life care costing information, NEoLCP, Apr 2012)

This list clearly demonstrates and supports the financial advantages involved in switching the emphasis. The pensions ‘black hole’ is non-sustainable; ipso facto, neither are pensioners. 

The argument is a clear and favourable one, to protect the elderly, the frail and fragile, the vulnerable from 'dangerous hospitals'. This will ease and facilitate the policy to lower expectations, to shift care from the curative toward the palliative. Better to ration scarce medical resources by not providing them.

This is a consequence of adopting the Communitarianism promoted by Ezekiel "Zeke" Emanuel and Don Berwick. The latter has been appointed Guru to straighten out the NHS.

The Guardian author sums up:

For commissioners, the challenge is clear – they must shift resources from acute hospitals to community-based care, including hospices, care homes and people's own homes. What we have learned over the past twelve months provides us with the evidence base required for such a shift. 

The first step will be to ensure that community based end of life care is a top-level local priority. The second, that local commissioning encourages co-operation and co-ordination, so that people get the services they want and need. 

The ongoing pressures set out above underscore why we need such a major shift now. Rebalancing of care for dying people will not only help ensure the long-term sustainability of the health and social care system, but also give people more of what they want. This can only be good news for both individuals and the system. 

Dr Phil McCarvill is head of policy at Marie Curie Cancer Care.

Rebalancing care for 'dying people’…? 

What if our elderly require curative hospital care? Should they still be kept out of hospital because hospitals are ‘dangerous’? Isn’t it time to make our hospitals safe...?

What do we know now that we didn’t know a year ago? here confirms the 2013 CQUIN –

16. What we know about other research relating to end of life care... 

16.8 Impaired cognitive function is an independent predictor of mortality.
(Source: Sampson EL., et al., Survival of community-dwelling older people: the effect of cognitive impairment and social engagement. J Am Geriatr Soc. 2009 Jun;57(6):985-91)

It is the financial argument which is paramount in this discourse, and 'long-term sustainability'. It is the rationing of scarce resources. The author argues that 'this can only be good news for both individuals and the system.' That will not be the case for those connived to accept palliative in place of curative care.

In conclusion,  Healthcare Professionals Network 

reports -

• 94% of relatives/carers were given a full explanation of the care plan (LCP); healthcare professionals were able to discuss this with 56% of people at the end of life

Another doctor once said, 

“It would not be impossible to prove with sufficient repetition and a psychological understanding of the people concerned that a square is in fact a circle. They are mere words, and words can be moulded until they clothe ideas and disguise.” 
― Joseph Goebbels

“The bigger the lie, the more people will believe it.” 
― Joseph Goebbels, Die Tagebücher. Geschichte & Vermarktung

Liverpool Care Pathway - A Canadian Perspective

"I would not like to see us in Canada slide down this slippery slope. It is reminiscent of the “final solution” during the last war."

JUNE STEVENS, Windsor

This is the view from The Windsor Star -

THE WINDSOR STAR

The Liverpool Pathway is very disturbing

SoapBox
Mar 25, 2013 - 11:27 AM EDT
Last Updated: Mar 26, 2013 - 3:12 PM EDT

I want to draw your attention to this subject which you can Google for more information.

It is regarding the ethics of euthanasia and how this is impacting severely ill seniors and their relatives in Britain. Many of them are increasingly worried about the so-called Liverpool pathway, as are the seriously physically challenged.

Not all patients or their relatives are informed by the medical staff that the patient has been placed on this Pathway and as the patient has food and life support withdrawn from them at this point, this has serious ethical and legal ramifications.

Some patients are unaware that they are being allowed to die and did not give their consent.

There are many lawsuits ongoing at this point. Some patients are put on this Pathway by junior doctors and the patient’s regular doctor is unaware this has taken place.

Speaking with relatives in Britain, it is quite apparent many cognizant elders are now “terrified” of going to their local hospital for fear of what will happen to them. How sad and quite frankly outrageous.

I think it merits a serious investigation from the Canadian point of view and it would raise many interesting points regarding end of life discussions here in Canada. It would be interesting to hear what our medical and religious leaders and the general public think about this protocol called The Liverpool Pathway.

I am appalled to learn that there is a payment made to the hospital by the government when this protocol is followed. I personally would want to make my own decisions about what appears to be, in my opinion, euthanasia, or at least have my relatives make the decision.

I would not like to see us in Canada slide down this slippery slope. It is reminiscent of the “final solution” during the last war.

JUNE STEVENS, Windsor

  Comment  

Annette Wood · Ordsall high school
my mother was placed on the LCP and we didn't know what it was.we were told that they were going to make our mum more comfortable she lived for 4 days , she didn't meet any of the criteria for the LCP tickbox document , she had a collapsed lung which was re inflated, and she was due to come home until a junior doctor said mum had the matter of 4-6 hours to live then she was placed on the LCP and died 4 days later.We were told not to give her food or water as this would make her worse , we had to watch our mother suffer begging for food and water for 4 days.it wasnt till after her death that we had a meeting with her consultant who went on to say we could have given her food and water , she may of lived but we will never know now , we have made a formal complaint and still waiting to hear the outcome , my mum didn't deserve to be treated like this , this has to stop now , since mums death we have opened a group on facebook called HELP PUT A STOP TO THE LIVERPOOL CARE PATHWAY and we have lots of members who have been through the same as our family the hospital where my mum died recieves CQUIN PAYMENTS for putting people on lcp , unless you have seen this or have gone through this process you will never know how barbaric this is surely its against human rights this has to stop NOW.

Liverpool Care Pathway - Unconstitutional And Inappropriate

The Liverpool Care Pathway is being used without knowledge and, where there is knowledge, without permission or consent. Can this be right?

Both Mr. Hunt and Mr. Lamb have gone on record as saying that it should not be used without knowledge. Would they not agree, then, that it should not be used without permission...?

The Mental Health Act permits compulsory medical treatment under certain circumstances.

In the matter of communicable (contagious) diseases/infections, compulsory medical treatment may also be permitted. 

Neither is the case here.

In the matter of enacting other medical procedures, a consent form is procured and presented to the patient to sign. Why is this not so in the case of the LCP? 

LCP literature states that it is a ‘framework for best practice’. This means that the issue of consenting to the LCP is not relevant as consent is only applicable to a medical treatment.

The LCP is not a 'medical treatment'; it is a framework, a care pathway.

Here, Gordon D. Rubenfeld, MD MSc, discusses Principles and practice of withdrawing life-sustaining treatments -

It is stated here that -

5) Withdrawal of life-sustaining treatment is a medical procedure.

The LCP does involve withdrawal of life-sustaining treatments.

It may provide for the withdrawal of nutrition and fluids, for instance; it may involve withholding and/or withdrawing life sustaining treatments such as artificial hydration and feeding, oxygen, ventilation, dialysis; not attempting resuscitation in the event of cardiac arrest.

The withdrawal of life-sustaining treatment is a medical procedure and part of this medical procedure is the novel prescribed treatment with medications specific to the pathway.

The LCP is both medical procedure and treatment; it is both compulsory medical treatment and compulsory medical non-treatment.

The LCP, therefore, being compatible with Section 2a of the NHS Constitution (the Health Act 2009 requires NHS to have regard to the constitution) is not being used appropriately.

Section 2a states: “You have the right to accept or refuse treatment that is offered to you" and "be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available."

Liverpool Care Pathway - "BE PROUD, BE LOUD, BE HEARD"

Age gets to us all such that we may become not quite the people we used to be or thought we were. The important thing is to stay true and always be ready to stand up and be counted.

Read Toyah's blog from NOVEMBER 2012...

This is Toyah in her own write --

NOVEMBER 2012

HELLO AND HAPPY PRE-CHRISTMAS!

NOW FOR THE SERIOUS BITS….

Last week I was asked to give an interview to BBC NEWSNIGHT about the attitudes to women during the 1970s and 1980s. This was a tricky one to do without implicating every man I have ever known, but the fact of the matter is women were living in a completely different world 30 years ago to the world we inhabit today. The main difference being was 30 years ago women were supposed to be flattered if a man was inappropriate towards her. Trying to word this without sounding like Mary Whitehouse was really bloody hard.

Also my big enemy Mercury In Retrograde starts this week for the rest of the month, which can mean my being misrepresented in all forms of communication. But NEWSIGHT asked me before hand to write down my experiences briefly and I wrote……..

"My memories of the 1970s was that most men under the age of 30 aspired to sleeping with school girls. Most musicians I knew at the time liked to hang out at the school gates at hometime. There was a very definite and accepted culture of perving after girls in school uniforms. I count myself lucky that I wasn't a 'looker' because if I was I would have been constantly targeted and under pressure to give sexual favours. Within music, there was a very strong tendency for women to have to 'give out' to get somewhere in showbusiness. This was the period of the Yorkshire Ripper. Women were not as protected as they are today. I truly believe at this time some men admired the ripper. Even though I believe children today have more under aged sex than ever, I believe they are having it with their own age groups, not older men. Times have changed.a lot and for the better.

"Back then women were seen sexually before intellect. Jimmy Savile's behaviour is totally wrong, but there were many men around his time who sailed as close to the forbidden boundary as Jimmy, but Jimmy took it into a life of exploitation and perversion. Everyone named in the past weeks, Jimmy, Glitter, Starr all took immense pleasure in humiliating women in public and to their faces. I have nothing but bad memories from meeting them all. But I have no solid evidence of them abusing other than humiliation."

What really spooks me about these past sentences is they were written on the 26th October and now Savile is linked to the Yorkshire Ripper!

The pressures of the last month didn't ease with doing NEWSNIGHT. I feel we are looking at a "historic period" that all have moved on from, especially in the context of women. BUT then all the news kicked in about the LIVERPOOL CARE PATHWAY which led to the realisation my mother was told she had been put on this whilst she was alone, without any family with her to support her.

Mum went into the hospice on the Friday, expecting to be assessed and to come home, but her health deteriorated rapidly and by the Monday it was obvious to us she wasn't going to make it home. I performed at Manchester Pride on the Monday and went home to bed afterwards, expecting to see mum Tuesday lunch time onwards. On the Tuesday morning, four days before she died, I had a call from a nurse saying "your mother has had a bad episode; please don't worry but can you come in."

"what do you mean, is she about to die?" 

"No she is upset about something…………."

I thought this was because she had been moved into a single room. I drove straight around to the hospital where my mother was in a full panic attack with a nurse saying "it's OK Barbara the end is near." I asked the nurses never to talk to my mother like that again and they were very apologetic. I shed tears thinking of my mothers fear in this moment. I am not saying anyone has done anything wrong, but this language is brutal. Myself, my family and mums best friend didn't leave mum's side until she died, making sure she only had words of comfort in her last hours.

DON'T LET THE NHS BRUTALISE DEATH…………IT IS A DEEPLY SPIRITUAL AND TERRIFYING EXPERIENCE……….LIKE BIRTH!

On a happier NOTE! I cannot wait for Christmas. I cannot wait to be in Canterbury and performing in the show. This is my family now. Its funny but when I used to watch Judy Garland in A Star Is Born I always wondered how someone's life could hang on the tenuous surroundings of showbiz…………but this is MY FAMILY NOW!

BE PROUD, BE LOUD, BE HEARD
LOVE TOYAH
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Liverpool Care Pathway - Live And Let Die

It is one thing to cite such a tragic and extreme case as is promoted here to support a proposition that, actually, the cure may not be a ‘cure’ at all.

It is quite another to cite such a case as evidence in support of a blanket introduction of a protocol that is all-encompassing and applied without thought or measure.

It is, in fact, an argument that every case is an individual case and that every individual is individual.

This is Huffington Post  -

A 52-year-old woman came into our hospital in New York bleeding to death.She had advanced stage throat cancer. Her tumor, on the left side of her neck, was both pushing into her airway and a major artery. As the tumor grew, the woman could no longer breathe, and when her artery ruptured, blood started pouring into her lungs.
She would die by drowning in her own blood. 

Her husband was understandably overwhelmed and distraught. He instructed us to take any measures possible to keep her alive. She was too weak to contradict her impassioned and dedicated husband. 

This was, in my view, the wrong choice from an ethical and clinical perspective. How could I uphold my oath to do no harm when I knew she would die a particularly gruesome death, and I was instructed by her husband to keep her alive and in this state? I would have to crack her ribs during chest compressions and electrocute her to attempt to restart her heart. Regardless of whether we could keep her heart beating, the rest of her body would still be irreparably consumed by cancer. It was anguishing to be forced to inflict this sort of violence on this dying woman.

 [The Independant]

The recent focus on autonomy over decisions at the end of life in the UK, through Tracey's court case as well as controversy over the Liverpool Care Pathway, highlight the need for continued dialogue and clarity on these issues. The lawyers involved in the Tracey case have rightly affirmed that these decisions should not be made in the courts - a process that encourages suspicion and public anxiety.

[BBC News Cambridgeshire]