Liverpool Care Pathway - There Are Many Pathways...

The many-headed Hydra has spawned a thousand children. And they're all jockeying for pole position.



Some, however, have simply donned a cape beneath which to conceal the uniform of their true loyalties.

This is Wirral Community NHS Trust - August 2013 and the "Wirral End of Life Care Plan" -

End of life care (EoLC) does not focus just on the last few weeks of life. Any person who may be in the last year of life due to a condition or illness is considered for EOLC; the above model; the Wirral End of Life Care Plan summarises the key stages for end of life care. All patients should be registered on the Gold Standard Framework (GSF) held by the GP Practice during the last year of life.

All community and specialist nurses are required to follow this protocol and comply with mandatory training in its implementation. This is not a personal care plan; this is the LCP.

The final page confirms this. The Control Record actually says -

"Change of name from Liverpool Care of Dying Pathway to Wirral End of Life Care Plan as instructed".

It's an Orwellian Newthink: "The EOLC programme aims to help individuals to live and die in a place of their choice reducing the number of people being unnecessarily admitted to hospital in the last weeks/days of life, and ensuring that the services they receive are appropriate to their needs and preferences whenever possible". 

That means if you've been selected for your GP EoLC list and you need an ambulance, don't call us; we'll call you. The Palliative Care Team will be right round with all the comfort care you need.

Page 2 leads into this - 

EOLC ESSENTIAL QUALITY STANDARDS WITHIN THE TRUST 

If these quality standards are not met then a rationale must be recorded in the patient’s health records

• All palliative care patients diagnosed as being in the last year of life and on End of Life Care Plan will have an Advance Care Plan in the form of a ‘Patient and Carer Assessment’ (PACA). The PACA is a comprehensive holistic assessment which is responsive to the changing needs and preferences of patients and carers 

• All patients must be offered a Preferred Priorities for Care Document and this must be recorded in the patients’ health records 

• All patients approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences and recorded in the PACA 

• All patients will have their pain assessed and recorded at every visit, preferably on the PACA to support continuity of care 

• All patients will have a nutritional screening assessment using the Malnutrition Universal Screening Tool (MUST) to identify patients at risk of malnutrition according to the patient’s clinical needs. For patients identified at risk following a MUST assessment, a nutritional care plan will need to be in the records 

• All patients should have medication prescribed for ‘anticipatory prescribing’ as per Wirral Care of the Dying Guidelines according to patient’s needs. 

• All patients approaching the end of life who may benefit from specialist palliative care are offered this care in a timely way appropriate to their needs and preferences 

• The PACA should include the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) status of the patient. 

• All informal main carers must be offered a carer assessment, if carer declines this must be documented in the patients’ health records 

• All patients will be commenced on the Wirral End of Life Care Plan. 

• All patients will have a syringe driver set up within 4 hours 

• All patient records will have evidence of Out of Hours referral updates at least monthly 

• All carers will be offered bereavement support visit

The PACA is an Advance Directive. This is an holistic assessment reached conjointly with Patient and Carer(s), hence PACA. This is not to be confused with 'holistic' as it is used in so-called 'alternative medicine', however.

An assessment is made that is no better than a forecast - a guess - that EoL is at hand and discussions proceed on that basis between the groomer (the Healthcare Professional) and the groomed (the Patient and Carer(s)).

Ongoing discussions will add to and modify the PACA. 

Beware what you agree to... When the end is at hand you may wish that you didn't.

Wait a minute. The Wirral says all palliative care patients will have an Advance Care Plan -

All palliative care patients diagnosed as being in the last year of life and on End of Life Care Plan will have an Advance Care Plan in the form of a ‘Patient and Carer Assessment’ (PACA)

Will. Even should they decline to...? There is a provision in the document for if the carer(s) should decline and that this should be noted but not if the patient should decline.

Upon implementation of the Wirral, a driver will be set up within 4 hours. 

This is a nightmare version of the LCP.

If Kathleen Vine had been put on this, she wouldn't have woken up...

TRIGGER QUESTION

Trigger question for assessment to decide if the patient may have end of life needs regardless of diagnosis

• The surprise question, ‘’ Would you be surprised if this patient were to die in the next 6-12 months’’ – an intuitive question integrating co-morbidity, social and other factors (Gold Standard Framework, 2008).

This is not science or medicine; this is quackery. This is the medical equivalent of stepping out of the realm of Astronomy into the realm of Astrology. To make such a decision to downsize healthcare options on the basis of a 'surprise' question is no more than a weather forecast. But that's the so-called Gold Standards Framework for you...

This is the LCP OTT.

ASSESSMENT AND PALLIATIVE CARE STANDARDS

The advance care planning in the community ‘insight score’ can be completed at initial assessment or at a later date if patient is not aware of prognosis or reluctant to talk about end of life care. However, this does not stop initiating appropriate conversations for advance care planning or end of life care

This is grooming. The next paragraph in the document on Frequency of Contact demonstrates this - 

"regular ongoing visits promote proactive management of patient care which evidence suggest helps to reduce unnecessary hospital admissions".

Regular visits reinforce the grooming process. The patient is groomed by nursing staff themselves groomed to comply with and agree to the ethos.

This is a cult.

There will be 'guided discussions'.

If patient and/carer are finding it difficult to talk about end of life care issues after a number of visits, regarding their concerns or their PPC, seek advice from the End of Life Care team as further specialist advice may support future advance care planning and timely communication.

If the situation arose - as it did with Kathleen Vine - that they needed a bit of extra persuasion that dying was not a possibility but a certainty, they'd send in the heavy grooming squad.

"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely - and he came in and he was sort of asking us if we'd thought about the funeral and how we were going to tell our daughters, and just, sort of, getting us to talk about it, I suppose. And I was saying, I just can't believe it. You know, she came in with a dislocated shoulder ; we're now being told she's dying. Nanny woke up at that point. And she had a full on conversation with him. She actually flirted with him. You know, she was saying, ooh, aren't you lovely? You've got lovely eyes. Surely, that's not a dying person. She's chatting you up, asking if you'll feed her... This, this can't be right, you know."[ Laugh...] - Kathleen Vine's granddaughters  - The Report

The Oncological ECOG tool is also applied. This is a case of a tool being misapplied, surely, to make imperative the palliative response!

The Pathways are rolled out across non-hospice settings, intended for use in all cases, of non-cancer and non-terminal diagnoses also. The patient is determined to be and is 'diagnosed' as - dying! How may an Oncological tool be used in such a setting?

Uncertainty is become certainty and the patient is doomed.

Page 7 leads into this - 

DO NOT ATTEMPT CARDIO PULMONARY RESUSCITATION (DNACPR) 

 The PACA should include the CPR status of the patient. This decision should have been discussed at the GSF Practice meetings or with the GP.

‘’If the patient has an irreversible condition where death is the likely outcome the patient should be allowed to die a natural death and it may not be appropriate in these circumstances to discuss a DNACPR decision with the individual’’ 

(Trust Policy ‘Do Not Attempt Cardio Pulmonary Resuscitation’)

Presumably, in this case, the PACA has been agreed to and contains the relevant DNACPR status of the patient and this is positive. In such a case, the above-stated Trust Policy may not be seen to be at variance with legislation or policy.

However, such a statement made so readily and forthrightly is foolhardy and fraught indeed given this GMC ruling -

16 July 2012 

The General Medical Council has ruled that the failure by a doctor to consult a patient and their family before imposing a Do Not Resuscitate Order (DNR), a failure to record clear reasons for a DNR and an inappropriate use of DNR are all reasons  “capable of amounting to impaired fitness to practise”.

The decision follows the case of Barbara Evans who died in December 2007 at the age of 84. 

- Leigh Day

And yet...

Well, what have they to fear? They have executed or been a party to a medical holocaust and they have, apparently, got away with it.

And...

Well, this is convenient -

CORONER’S LETTER

Managing expected deaths out of hours requires a co-ordinated approach across all agencies. To help avoid any unnecessary stress or inappropriate calls to the police or ambulance service, the Wirral Coroner’s Office has written a supporting letter attached to each Wirral End of Life Care Plan.

There has also been a politically correct 'equality assessment' to ensure there is no possibility of any discrimination or exclusion of any 'protected characteristic' and that this veritable tool may find universal benefit to all.

That makes it all okay, then.

This truly is a nightmare version of the LCP.

This is a mishmash LCP.

It is still the LCP.

Mr. Lamb...?

Denise...?

Anyone?

Liverpool Care Pathway - Carry On Up The Pathway

When is the Liverpool Care Pathway not the Liverpool Care Pathway?
When it's the Liverpool Care Pathway...?



This is on Palliative drugs forum -

Liverpool Care Pathway

Posted by: Mrs Sarah Charlesworth (IP Logged)

Date: August 12, 2013 10:28AM

Many thanks go to Dr Saskie Dorman (Poole Hospital NHS Trust, UK) for sending us their Personalised Care Plan for the last days of life, an interim set of documents incorporating and building on the principles of good care outlined in the Liverpool Care Pathway, which has been discontinued in their NHS Trust. Comments or suggestions for improvement have been requested. 

We have added these 4 documents to the document library under the topic of End of Life Care (palliative care pathways). We would like to encourage members to donate more documents on this subject (with the author’s permission), for the benefit of all our members. Please send them to us at hq@palliativedrugs.com. In addition, if you are a UK health professional, please complete this month’s survey ‘Liverpool Care Pathway- What are you doing?’

Just change the logo and the headed notepaper...

For all intents and purposes this is the Liverpool Care Pathway documentation.

- NHS Lanarkshire

This is the NHS Lancashire Liverpool Care Pathway (Hospital Version) -

Patient awareness of dying; religious/spiritual needs assessed...

Ongoing assessment of symptoms

 - Nursing Care Plan

This is the Poole Hospital NHS Foundation Trust Personalised Care Plan for the Last Days of Life -

Patient recognition of dying; religion and spirituality needs assessed...

symptom management consideration

There is also a Community Version and a Care Home Version of this LCP document.

The Poole document is in four parts -

The Nursing Care Plan

The Medical Care Plan

The Personalised CarePlan (Daily)

Personalised Care Plan for the Last days of Life - Guidance for Nurses

This is the same tick box Pathway, Mr. Lamb. Seems like 'Change the Name' is the name of the game. Switch branding and carry on as before. Same train, different livery. It's still Murder on the Death Pathway Express. 

On the front of the document there is a reminder to apply the principles of the Mental Capacity Act 2005. But you don't have to ask the patients' consent if you feel a discussion will be too distressing for them. Oh, well… Acting in the patient’s best interests and all that.

Advice is given that patients who are thought to be dying should usually be prescribed medication for the relief of pain, nausea, vomiting, restlessness and respiratory tract secretions, unless there are contraindications.

No mention is made as to what to do if there are contraindications, however...

Advice is given to "Stop investigations, interventions or treatments that won’t promote comfort, dignity and peace".

You don't know if you don't try. Never mind, just give up and tick that box, job done!

The three LCP documents each include a space for a named Macmillan Nurse. Macmillan and Marie Curie must also answer to the medical holocaust that has proceeded.

- Mail Online

And according to a survey reported today, a third of cancer patients do not trust the nurses treating them.

The Brand is all and what brands they are! All that and still come through it looking squeaky clean...

"It is myself I mean, in whom I know
    All the particulars of vice so grafted
    That, when they shall be opened, black Macbeth
Will seem as pure as snow..."

Act 4, Scene 3, Page 3

Footnote: 

Advice on clinical management - Edited by the Wessex Palliative Physicians

The Palliative Care Handbook (PDF 426kb)

Liverpool Care Pathway - It's A Green Light For The Way Forward

The lights are at amber;
They're all set to go.
The CQUINs are ready-
As if they didn't know!



 
This is the 'tool' they used to dig your grave; the LCP was the 'tool' they used to toss you in it.

If idle talk costs lives, this is going to cost plenty. There is much backchannel chatter on the network.

On the Twitter network:

 
Katherine Sleeman ‏@kesleeman -
"Twitter drs/nurses: can you help me w some research for a talk? Is #LCP still in use where you work? Or gone? Very grateful all responses :)"
 
Ellie ‏@ellieornot -
"@kesleeman Still used where I work. Rather not say where publicly. Only recently rolled out on some wards (last 6 months). Has meant"
"huge improvement in Pall Care delivery. Prior to that most nurses in gen wards had no training in EoL care, no familiarity"
"..with meds. Was real fear of EoL management. That has thankfully changed since LCP intro."
"My exp of it good. Only ever seen it used appropriately, after careful contemplation & where possible discussion with family."
 
susan nattrass ‏@NattrassSusan -
"@kesleeman still offically in use but drs saying for tlc and writing up drugs from lcp ... so still lcp but no paperwork nurses usual care"
 
Benjamin Bloch ‏@Bloch_ortho -
"@kesleeman Principles of LCP still being used but has a new name. Looks identical to me tho."

Katherine Sleeman ‏@kesleeman -

"@Bloch_ortho thank you. New name since review?"

Benjamin Bloch ‏@Bloch_ortho -

"@kesleeman Can't remember exactly; something like amber bundle? Amber something, anyway. Looks exactly like LCP..."

Claire Dickens ‏@ClaireLDickens -

"@kesleeman we are recommending continuing use for now. Use def dropped off tho. Some wards still confident to use, some less so"
 
Kate Granger ‏@GrangerKate -
"@kesleeman We have been advised by SPCT to continue using pathway. In reality most of us in Elderly Med aren't & using principles instead..."
 
Nintendo Police ‏@Rhincodon_T -
"@kesleeman @GrangerKate the #LCP was withdrawn where I work as soon as the negative stories surfaced in the media."
 
bridget coady ‏@coady98 -
"@kesleeman @GrangerKate Consultants are now not happy to use LCP shame as when used well its so beneficial"

TryingtobeaJuniorDr ‏@tryingtobeaDr -

"@kesleeman @GrangerKate gone, under instruction of chief exec."

Heather Lewis ‏@heatherilewis -

"@kesleeman @GrangerKate Gone where I work. Stopped the week of the report by chief exec due to concerns of loss of confidence by public"

Phil ‏@NCFC1979 -

"@kesleeman @NurChat we use the LCP @CUH_NHS, however there does appear to be hesitance to start the LCP possibly due to bad publicity."

"what I like about the LCP as a nurse it provides guidance and reassurance, key element is to communicate to the NOK."

[My note: CUH = Cambridge University Hospitals = Addenbrookes]

Fabrizio Motta ‏@cinghio81 -

"@kesleeman still in use in our hospice ward; still in "experimental" phase its use in internal med wards. Yes we're running 10 yrs late..."

Katherine Sleeman ‏@kesleeman -

"@cinghio81 'experimental phase' suggests a test which can only be a good thing. Thanks."

Fabrizio Motta ‏@cinghio81 -

"@kesleeman we can only hope so as #hpm awareness is growing in Italy #hpmglobal"

[My note: hpm = hospice and palliative medicine]

laura vincent ‏@mrsbungy -

"@kesleeman still considered gold standard where I work but only following proper conversation with family"
 
Trisha Macnair ‏@bluebass2 -
"@ibundle @kesleeman Our guidance is to stand by general principles (simply good and frequent symptomatic care) without the formal LCP" 
Paula Tucker ‏@ibundle -
"@bluebass2 @kesleeman do you think care has changed as result of what's happened with #LCP ? Sounds like not"
 Trisha Macnair ‏@bluebass2 -
"@ibundle @kesleeman Not really. We have always individualised it and give plenty time to family, to explain approach and ask if they agree"
 
qp nell ‏@qpnell -
"@kesleeman much confusion in primary care. GPs no idea & nursing homes worried about implications of using LCP now."
 
wishiwasgold ‏@wishiwasgold -
"@kesleeman still there (ie not rescinded) but not used... #LCP"

Terri Freeburn ‏@terrifreeburn -

"@kesleeman @NurChat nope, I work in a specialist palliative care unit and lcp stopped a few weeks ago!"

Liz Sampson ‏@DrLizSampson -

"@kesleeman still using principles just with the name and documentation dropped. Refs to pall care gone up as gen staff confidence gone down"

Toby Hillman ‏@tobyhillman -

"@kesleeman not in use at my place. Mandated day after the report published. Alternative not widely publicised - not had need myself recently"

Katherine Sleeman ‏@kesleeman -

"@tobyhillman thank you. So, there is an alternative in place? Do you know what?"

Toby Hillman ‏@tobyhillman -

"@kesleeman I don't know if there is a specific replacement, more just generic principles. But not certain - (good eg of the problem!)"

Kate ‏@Knit1jog1 -

"@kesleeman we're not using the paperwork but very much the principled. (Palliative care huge part of Respiratory really)"

Elin Roddy ‏@elinlowri -

"@kesleeman We still using, but have (re) formed whole health economy EOL group and am writing new 'End of Life Plan' for use in all settings"

Katherine Sleeman ‏@kesleeman -

"@elinlowri thanks. Interesting. All settings as in community/CH/hosp? What will you do if/when national replacement comes out?"

Elin Roddy ‏@elinlowri -

"@kesleeman Yes all settings. If national replacement fits us will use, but we decided couldn't wait in limbo that long as EOL care wd suffer"
"Already reluctance to write up end of life meds if patients 'not on LCP' - we have become so used to it that need something to>>"
">>clearly signal to staff (and obviously pts & their families) what the focus of care is otherwise we risk (even more) confusion"
 
Shaun Lintern ‏@ShaunLintern -
"@kesleeman What are you doing with the info?"
 
Katherine Sleeman ‏@kesleeman -
"@ShaunLintern its for a talk to London Cancer Alliance. Want a feel for how many trusts following 6/12 guidance & how many have ditched it."

This is the Quality Account of the Burton Hospitals NHS Foundation Trust -

Pages 25 and 27 discuss The Amber Care Pathway or 'bundle'. Mr. Lamb said not to mention the Pathway... And they think they've got away with it.

During the year the Trust has undertaken an end of life audit, which has identified areas of improvement which have been implemented. This will assist with the work required in 2013/14, as the Trust participates in the national AMBER CARE bundle 

Page 27 of the Account discusses the CQUIN payments and provides a table of those schemes eligible to qualify for CQUINs.

Areas for CQUIN payment framework in 2013/14 -

The CQUIN schemes for 2013/14 have been determined following discussions with Commissioners and also through areas identified nationally as topics for further quality improvements. Some of the CQUIN topics have been carried over into the new operating year, but given renewed focus and further standards for achievement. The table below details the extensive set of CQUIN topics, along with their rationale for inclusion in this year’s contract.

'End of Life' is one of the areas carried over into the new operating year. 

The 'Rationale' is 'Implementation for patients in whom recovery is uncertain'.

Say that again?

"Uncertain"! They have actually broadened the scope of the Pathway Bundle! And the CQUINs are in place!

They're being paid to seek out the weak, the more frail and the vulnerable with a view to finish them off.

Why is not everyone up in arms who raised the hue and cry against the LCP? They're slipping this in under the radar.

Look, if you're going to have euthanasia, be honest and call it euthanasia. At least Philip Nitschke is straight about what he's about and actually points out the economic benefits of - well, to cut a long life short - limiting life!

And there's more...

This is from the Public Meeting of the Board of Directors of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust -

The local CQUINs  have a higher contract value (bounty) than the national ones. There is also a focus on admission avoidance which will ensure the local EoLC GP Register is reinforced and palliative rather than curative options are adhered to.

The Deputy Director of Nursing noted that the local CQUIN programme for 2013/14 had a higher contract value than the national one. The local programme had two key areas; firstly end of life care which followed from the 2012/13 quality accounts and focussed on patients on the amber care bundle (patients at risk of dying in the next one to two months) and would audit if these patients had died in their documented preferred place of death. The second focus was around working with Berkshire Healthcare Foundation Trust on admission avoidance and patient flow and pathways.

The National CQUINs are 0.5% of contract value; the local CQUINs are 1.5% of contract value.

Key issues, risks and actions arising from this paper:

• Risk of litigation if patient care falls below the required standard
• Significant financial risk if CQUINs not met (anticipated £4.8M)

£4.8 million... Loadsamoney! 

CQUIN

2013/2014 sees the first year of a pre-qualification criteria for the National and Local CQUIN programme which requires 50% compliance to enable payment for any achieved CQUINs. It is anticipated that the value of the entire CQUIN programme will be worth approximately £4.8 million.

Loadsa, loadsamoney!

End of Life Care

The EOL care CQUIN will focus on patient choice around preferred place of death. A bi-annual audit will be utilised to determine the number of patients on the AMBER care pathway and determine whether preferred place of death was achieved or not and factors contributing to this. 

This will contrive to ensure patient admission and patient 'preference' requirements are complied with and also maintain CQUIN targets. Pack them off home and make them comfortable.

Here is the Guy's & St. Thomas' NHS Trust Board Quality Committee -


End of Life care - Sustain and roll out AMBER care bundle; all new referrals on GOLD register & training & education -

CQUIN indicators for the quarters in 000s - 

£146, £694, £146, £694

Important Note: 

LCP use may have increased with earlier recognition of dying following the AMBER care bundle implementation.

Reduced in-hospital mortality.
There is a trend identified which may be at least partly related to the AMBER care bundle i.e. a reduction in-hospital mortality associated with the bundle having been rolled out across key wards in the Trust.


The graph records the number of in-patient deaths across a six-year period from 2006/01 to 2012/01. A median figure of 91 is recorded for the period up to 2011/01. A median figure of 83 is recorded for the period 2011/01 up to 2012/01.

A median figure is exactly that; it is the ‘middle’ figure. Statistically, a median is useful for detecting a trend, but figures and statistics can be used to demonstrate something - anything - not inaccurate in itself, but by interpretation inaccurate.

It is difficult to accurately discern from the graph depicted the recorded mortality figures, month by month. However, a cursory glance at the graph suggests a significant median shift from the period 2006/01 to 2007/11, approaching 2008/01, to the next.

The graph appears to indicate a trend of higher in-patient mortalities with notable peaks above the median line during the period 2008/01 to 2011/01. What caused that..?

Was there a 'great leap forward' during this period to press ahead with Pathway implementation? Were Chairman Ellershaw's red guards Bee-ing ahead about their business?

The DoH had committed to investing 286 million pounds over the two years to 2011 to support implementation of its National End of Life Care Strategy.

This document was jointly written by the National Council for Palliative Care and the National End of Life Care Programme -

"The purpose of this briefing is to help you to identify the immediate priority actions to commission effective end of life care, focusing on steps which we believe will make the most difference initially and can be seen as ‘quick wins’."

"Quick wins". They're talking about people...

"We are investing £286 million over the two years to 2011 to support implementation of the End of Life Care Strategy to help improve end of life care for all adults, regardless of where they live.”- The Telegraph

Loadsa, loadsa, loadsamoney...!

Responding to the apparent statistical median shift attributed to implementation of Amber, this is more to do with nursing staff paying attention than to the EoL pathway. As has been shown to be the case, better care means better outcomes and more attentive care is better care.

In addition, if it is policy to parcel them off home for 'comfort care' then, of course, you are going to see a reduction in in-patient deaths.

The AMBER CARE bundle

The AMBER care bundle was developed at Guy's and St. Thomas' through an initiative that was funded by the Guy's and St. Thomas' Charity. It was developed to improve the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment.

AMBER is now ‘live’ on 21 wards at GSTT. We have seen the number of patients cared for on AMBER increase by over 150% in the past financial year (201 in 2010-2011, vs 543 in 2011- 2012). AMBER is also being rolled out to 25 Trusts nationally, through the national ‘End of Life Care Route to Success’ programme, with 15 further hospitals interested in becoming AMBER sites.

This is the Isle of Wight NHS Trust Quality Account 2013 -

Priorities for Improvement for 2013/14 and Development of the Quality Account

Priority 1: Reducing Mortality rates
Priority 2: Prevention of Pressure Ulcers
Priority 3: Improving Communication 
Priority 4: End of Life Care (AMBER Care Bundle)

The AMBER care bundle© was developed at Guy's and St Thomas' NHS Foundation Trust through an initiative that was funded by Guy's and St Thomas' Charity. It was developed to improve the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment.

It has been noted elsewhere and previously that use of the Amber Pathway actually improved uptake by the Liverpool Pathway. We have been here before. It is not possible to 'diagnose' dying. And "here we are again, dying as can be...!"

The Isle of Wight NHS Trust is keen to implement the AMBER Care Bundle to make it easier for Nurses and Consultants to have appropriate planning conversations with patients whose recovery is uncertain, thereby enhancing the patient experience and care of patients with palliative care needs and enables patients to be involved in decisions about their care and where they wish to die.

With the LCP, they had 'that' conversation with patients who 'are' at risk of dying.

They are now going to have 'that' conversation with patients who 'may be' at risk of dying. This is not just seeing the glass half empty instead of seeing the glass half full; it is actually tipping the water out to half-empty the glass!

There is also a Priority of Care to reduce mortality rates. Well, that's handy, Harry. Put them on the pathway bundle and their backs are covered.

In many respects, this is worse than the LCP; it is more broad, more all encompassing; it is trawling the net 'wider than before, better than before...' This is the six million dollar plan!

Conceding a position on the field of battle has won them the war. NOT!

Key performance indicators for 2013-2014 

Implementation Number of agreed wards using the AMBER Care bundle – target  100%
Evaluation & Impact Audit of patients’ healthcare records in January 2014 – 60% of  patients audited have completed AMBER care bundle

Dementia is a significant challenge for the NHS with an estimated 25% of acute beds occupied by people with dementia, leading to increased length of stay due to delays in leaving hospital. It is for this reason that it is necessary to single these people out and find them and it has been made a Quality Account priority for 2012/13. Thus, there is a CQUIN or bounty in place in the dementia hunt for 2013.

The scheme includes all patients aged 75 and over admitted with a length of stay longer than 72 hours (excluding those with known dementia or clinically unfit for assessment). It requires that over 90% of these patients are asked the Dementia Screening Questions. Subject to the result of this screening process, the provider is then required to undertake an Abbreviated Mental Test score (AMT) on more than 90% of this cohort. Finally if the patient scores 8 or less on the AMT, then at least 90% of these should be referred to the Memory service (or other appropriate service).

The Isle of Wight NHS Trust needs to achieve the following as part of the FAIR (Find, Assess and Investigate, Refer) dementia process:

• Find - 90% or greater of eligible patients screened (75 and over staying greater than 72 hours) asked the dementia screening question.

• Assess and Investigate – 90% or greater for those patients identified as failing the dementia screening question as above, assessed using the AMT.

• Refer – 90% or greater of those with a score of 8 or less on the AMT referred onto the Memory or other appropriate service.

The above standards need to be achieved for 3 consecutive months in order to receive the associated CQUIN payment and for 100% achievement of the priority.

Everyone has memory problems and might fail that 'test', but the over-75's are singled out.

This is not diagnosis; this is categorisation.

Amber is taking off.

Recruiting at University College:

Audit of Acute Medical Unit and Care of the Elderly units in UCLH

- ucl medical society

A medical student is required to participate in auditing the medical notes of clinically unstable patients from the Acute Medical Unit and Care of the Elderly units of UCLH. This is in preparation for the AMBER care bundle due to be introduced in UCLH from January 2014.

Health Education West Midlands reports -

Using End of Life Care funding, Worcester Royal Hospital have rolled out AMBER across 12 wards and have spoken on a national platform about their work in this area. It is our intent to promote the adoption and spread of AMBER during 2013/14.

York Teaching Hospital recently appointed an EOLC Educator on a fixed term basis to focus on Amber and Advance Care Planning.

Hinchingbrooke Health Care NHS Trust -

The team will implement the ‘Amber Care Bundle’ on 2 wards, the bundle is a tool to identify patients who are at risk of passing away during their hospital admission...

And half way across the planet in New South Wales. An Action Plan 2013-2018 reports that Amber is being trialled Statewide.

Amber is here.