Liverpool Care Pathway - Retracting Their Footsteps

There was never any doubt. Normal service is being resumed...





This is from An information guide for Marie Curie Cancer Care staff and volunteers –

[The] LCP includes specific goals of care related to communication, spiritual and religious care of the patient and the family

 This is the document itself -

- Goal 6

Goal 6 of the document advises to consider specific cultural needs and the support of a chaplain or religious adviser.



A respect for religious convictions appears to be encouraged, not ridiculed...

The supporters of the Death Pathway, however, pursue their blind faith with an enthusiasm that hinges on fanaticism. Blinded to the truth that you may not reliably diagnose dying and deaf to the evidence that this is so, they stumble on in their misguided and mistaken conviction.

The following conversation was found on Twitter; it is in regard to the news article in The Mail, which follows.

It is pretty much typical of the bog-standard level of the LCP fan base. They have neither expertise nor argument themselves to put and so resort to base insult and just downright disrespect -

FW @frozenwarning -
"Dear @mailonline Dr Tony Cole is not a "leading medical expert", he's head of a shady Catholic pressure group that puts religion before care"
Paul Morgan @drpaulmorgan -
"@frozenwarning You make a good point. Typical of @mailonline to think it’s in the right because a vocal minority shouted and screamed."
"@frozenwarning Of course the reality is that they have set back palliative care by several years, condemning many to a painful death."
FW @frozenwarning -
"@drpaulmorgan Exactly, while holding up a man who puts sky fairies above patient compassion as some kind of expert."
Paul Morgan @drpaulmorgan -
"@frozenwarning #LCP - a good tool sometimes badly used. But @mailonline solution was to throw it away rather than improve training."
"@frozenwarning Utterly abhorrent. I feel nothing but contempt for such people and that awful rag."

They have no argument to counter the valid published arguments of this respected and respectable man of medicine and so do attempt to demean him with extreme language and insult, and use his religious beliefs as a stick to beat him with.

It was not a “vocal minority” who “shouted and screamed” but those who had no voice and who witnessed their loved ones cut down by the reaper’s scythe that is the LKP.

We know they have no respect for human life; this crass exchange on Twitter confirms they have no respect for religious or spiritual conviction, nor even the content of their own holy tract – the LCP!

They are cowardly and offensive. Time will tell and history will hear us out in our belief that they are utterly abhorrent. We feel contempt, yes, but stand in shock and agasp in awe at the arrogance of the arrogant.

This is Mail Online –

The article itself suggests - as does Dr. Tony Cole - that the LCP is forever banned.

The answer, my friend, is blowing in the wind and the wind carries with it the clamour of voices as vocal and vociferous as ever they were.

The LCP is alive and kicking down in Devon...

This interesting snippet is from the Northern Devon Healthcare NHS Trust Quality Assurance Committee Minutes –

Report to              Trust Board
Date Tuesday       26 November 2013
Agenda Number  2.2
Agenda Item        Quality Assurance Committee Minutes 10 September 2013
Sponsor               Andy Ibbs, Commercial Director
Prepared by        Geraldine Garnett-Frizelle, Minute Secretary
Presented by       Chris Snow, Non-Executive Director and Chair

The purpose of this paper is to present the minutes of the Quality Assurance Committee meeting held on Tuesday 10 September 2013, numbers 110/13 to 143/13.

Significant Issues of Interest:

• Item 138/13 – There has been a Devon-wide agreement to proceed with the Liverpool Care Pathway Version 12 as this helps staff and supports the training programme to provide palliative care.

138/13 EMERGING ISSUES

Liverpool Care PathwayAlison Diamond, Medical Director, updated the Committee on developments relating to the Liverpool Care Pathway.

The Committee was advised that:

• Following the Clinical Hotspot presentation relating to the implementation of Version 12 of the Liverpool Care Pathway which had been presented at the March Quality Assurance Committee meeting and approved, there had been a significant amount of national activity relating to the use of the Pathway.
• An independent review of the Liverpool Care Pathway was undertaken by the Department of Health and the findings were published in July with a number of recommendations that have a bearing on the NHS.
• The review and recommendations were discussed at a Devon-wide meeting and it was agreed to proceed to Version 12 as this helps staff and supports the training programme.
• Karen Ricketts, Consultant in Palliative Medicine, is undertaking an audit looking at the quality of the use of the Pathway to provide Board assurance that the Pathway is being used appropriately. An update of the audit results will be provided to the Quality Assurance Committee.    AD

Maureen Manser, Clinical Effectiveness Lead, advised that the Trust is also registered for the national End of Life Audit.

The Committee NOTED the verbal update on the Liverpool Care Pathway.

It was agreed at this meeting to proceed to version 12. It was agreed to proceed to version 12.

"The review and recommendations were discussed at a Devon-wide meeting and it was agreed to proceed to Version 12 as this helps staff and supports the training programme."

North Devon Hospice offered 'essential training' on version 12 at six sessions earlier this year. 

This is the North Devon Hospice Education Programme 2014 –

This is essential training for all qualified nursing home staff to introduce and discuss the Liverpool Care Pathway Version 12 that the North Devon healthcare community are using whilst we await further information about any National changes to use of the Pathway.

To 'introduce and discuss the Liverpool Care Pathway Version 12...'

In forging new paths, they are covering their tracks. In Surrey, they are retracting their tracks...

This is the Royal Surrey –

The Liverpool Care Pathway - a programme for delivering palliative care to people with a terminal illness - has been the subject of media and public discussion recently.

With continued speculation and uncertainty about the purpose and intention of the pathway, we want to ensure our patients and their families fully understand how and when we may implement the programme, and what it really means in practice.

In response to the recent media coverage about the pathway, and the Government's intention to change the NHS Constitution, the Trust has decided that from now onwards verbal consent must be obtained from either the patient (if possible), or the patient's next of kin, before the LCP is implemented. All such discussions will be fully documented in the patient's notes, and (if relevant) in the Liverpool Care Pathway (LCP) document.

Consultant in Palliative Medicine at the Royal Surrey, Dr Andrew Davies, has produced the following fact sheet to explain the Liverpool Care Pathway

Factsheet

• The Liverpool Care Pathway (LCP) was developed in the 1990s to facilitate good end-of-life care for patients dying in acute hospitals.
• The aim of the LCP is to improve the quality of death, not to influence the timing of death. In other words, the LCP focuses care on making those patients who are imminently dying as comfortable as possible. 
• The LCP is an integral component of the Department of Health’s End-of-Life Care Strategy. 
• The Royal Surrey County Hospital has endorsed the Department of Health’s End-of-Life Care Strategy and is a pilot site for implementation of the “Route to Success” (i.e. the Department of Health’s End-of-Life Care Strategy for acute hospitals). 
• A clinical decision whether or not to place patients on the LCP is always made after a multi-disciplinary team discussion (and an assessment that the patient is expected to die within a few days). 
• The Royal Surrey has taken the decision to seek verbal consent from carers (or  if appropriate the patient) before starting the LCP.
• Patients are regularly assessed to ensure that the LCP remains appropriate; patients whose condition stabilises or improves, and whom are not expected to die within a few days, are withdrawn from the LCP. 
• At the Royal Surrey, all patients on the LCP are reviewed by the Specialist Palliative Care Team. Patients are reviewed on the day of referral, at least every other day, and on the twice-weekly consultant ward round. 
• The LCP does not preclude the initiation or continuation of assisted hydration. 
• The LCP does not preclude the initiation or continuation of assisted feeding. 
• The LCP does not preclude the initiation or continuation of other medical (symptomatic) interventions. 
• The LCP does not endorse the routine use of sedation. 
• At the Royal Surrey, the treatment algorithms (decision making) within the LCP have been amended to ensure that appropriate medications are prescribed / dispensed. Sedative drugs are no longer included in the first line options for management of symptoms, and are only used if all other treatment options have been exhausted. 
• Euthanasia is illegal in the United Kingdom, and the LCP is not intended, as some have suggested, as “euthanasia by the back door”.

The LCP is...

" a programme for delivering palliative care"

When is a programme not a programme? When it's the...

"the treatment algorithms"

So, the LCP is a treatment? So, permission does have to be sought and should have been sought all along?

"the Trust has decided that from now onwards verbal consent must be obtained from either the patient (if possible), or the patient's next of kin, before the LCP is implemented. All such discussions will be fully documented in the patient's notes, and (if relevant) in the Liverpool Care Pathway (LCP) document."

Yes...

Mind, it is verbal and so it's their word against yours and, if you're the unfortunate victim in this Tragedy of Errors that is playing itself out, at the end of the Pathway you'll be a goner anyway and won't be around to challenge them.

And more retractions...

"At the Royal Surrey, the treatment algorithms (decision making) within the LCP have been amended to ensure that appropriate medications are prescribed / dispensed. Sedative drugs are no longer included in the first line options for management of symptoms, and are only used if all other treatment options have been exhausted."

...in order to cover their tracks.

Hang on...

Sedative drugs are no longer included in the first line options to ensure that appropriate medications are prescribed...

So the prescribing of sedative drugs might have been...

...inappropriate?

My word, what are they saying? What are they admitting to?

The Review hasn't changed much, but it has sent a quiver up their rear parts and got them to restring their bow!

And at the Royal Surrey, that’s what they’re doing...

This is the Trust Board Quality Account –

Quality Priority - 6. Develop the Supportive and Palliative Care Services
Improvement Goal - Improvement in the use of the AMBER care bundle. To receive <25% of questions with dissatisfied response for service evaluation for bereaved relatives satisfaction with end of life care  

3.6 Priority 6: Developing Supportive and Palliative Care services
The service has been well established and provides supportive care; palliative care; end of life care; and cancer survivorship. The RSCH was a pilot site for the DH ‘Route to Success’ end of life care – achieving quality in acute hospitals. In relation to the target set for responses to the bereavement survey, the Association of Palliative Care medicine for Great Britain and Northern Ireland (AMP), service evaluation of bereaved relatives, 51carers were sent the FAMCARE2 questionnaire, and 24 carers returned the questionnaire to AMP. In total there were 157 (38.5%) ‘very satisfied’ responses, 132 (32.4%) ‘satisfied’ responses, 34 (8.3%) ‘neither satisfied or dissatisfied’ responses, 2 (<1%) ‘dissatisfied responses, 17 (4.2%) ‘very dissatisfied’ responses (all from the same person), 31 (7.6%) ‘not applicable’ responses and 35 (8.6%) blank responses. These results mean that the Trust has met the 2013/14 target relating to bereaved relatives satisfaction with end of life care.

The Amber Care Bundle...

That's been so successful at Guys and St. Thomas', where it was developed, they were actually hauled over the coals in the independent auditor's report.

See, for instance, -

Liverpool Care Pathway - Missing The Plot

At the States of Jersey Assembley Questions on 22/10/13, the Connétable of St. Lawrence asked the following question of the Minister for Health and Social Services –

“Has the Minister given consideration to the independent review of the Liverpool Care Pathway chaired by Baroness Neuberger and entitled “More Care, Less Pathway” and, if so, will she guarantee that the Liverpool Care Pathway will no longer be used in the Island?”

So, when is the Liverpool Care Pathway not the Liverpool Care Pathway...?

When it's an...

"end of care life strategy, which is the care of patients and their families over the last year of someone’s life but there is also the end of life care pathway which is put in place within the last 48 to 72 hours as appropriate to ensure that the best possible care of good practice and good pain and symptom control is paramount and communication with the family is essential."

This is Hansard 22/10/2013 –

STATES OF JERSEY

OFFICIAL REPORT

TUESDAY, 22nd OCTOBER 2013

4.11 Connétable D.W. Mezbourian of St. Lawrence of the Minister for Health and Social Services regarding the independent review of the Liverpool Care Pathway and its continued use in the Island:Has the Minister given consideration to the independent review of the Liverpool Care Pathway chaired by Baroness Neuberger and entitled “More Care, Less Pathway” and, if so, will she guarantee that the Liverpool Care Pathway will no longer be used in the Island?Deputy A.E. Pryke of Trinity (The Minister for Health and Social Services):As to my answer to an oral question on a similar subject last month and confirmed at the States Members’ presentation, I can confirm that since the announcement of the independent review of the use of the Liverpool Care Pathway in England, the pathway has not been used in Jersey.  Clinicians in Jersey representing hospice, family nursing, home care, hospital and G.P.s (General Practitioners) have considered the findings of the review and agree that the Liverpool Care Pathway will no longer be used in Jersey.  The review strongly recommended that the use of the Liverpool Care Pathway be replaced within the next 6 to 12 months by an end of life care plan for each patient.  This individual approach to care has been adopted in Jersey since the review was announced.4.11.1 The Connétable of St. Lawrence:I am grateful to the Minister for this public declaration that use of the L.C.P. (Liverpool Care Pathway) in Jersey has indeed been discontinued.  The Minister told the Assembly on 10th September, however, that use of the Liverpool Care Pathway was appropriate and she has not told us in her response why the clinicians believe that it should be discontinued.  Does she still hold the view that it is appropriate and if so, why has she decided to discontinue its use?  The Deputy of Trinity:As I said many times, the Liverpool Care Pathway was a tool to ensure that end of life care is the best possible that can be achieved at that very vulnerable time for patients and their families.  As Baroness Neuberger suggested, the panel came up with: “Every patient should have an end of life care plan.”  It is good practice, to encompass that because that covers very many different areas like pain control, nutrition, et cetera. 4.11.2 Senator S.C. Ferguson:Would the Minister for Health and Social Services like to confirm that the end of life care plan is not the Liverpool Care Pathway but under another name?  Surely the treatment that she is talking about is common sense and to start calling it by pretty names ... would she like to explain what the end of life care plan is and to confirm that it is not the Liverpool Care Pathway under another name?The Deputy of Trinity:There is the end of care life strategy, which is the care of patients and their families over the last year of someone’s life but there is also the end of life care pathway which is put in place within the last 48 to 72 hours as appropriate to ensure that the best possible care of good practice and good pain and symptom control is paramount and communication with the family is essential.  It is good practice and good nursing care and clinical care that this happens.4.11.3 Senator S.C. Ferguson:Is it always possible to tell that it is the last 72 or 48 hours of somebody’s life?  Surely only God knows that. The Deputy of Trinity:Indeed, no clinician - I cannot think of the word I am looking for - can see into the future but clinicians and nurses with the patient and their family can tell when someone is coming to the end of their life and to ensure, if that is the case, that the best possible care is put in place. 4.11.4 The Connétable of St. Lawrence:I think there is confusion about the use of the Liverpool Care Pathway, its demise in Jersey and the fact that we are still waiting for the full business case on end of life care, which in June 2012 was promised to us by the autumn of 2012.  When will the full business case on end of life care be available and be presented to Members for their consideration? The Deputy of Trinity:That work is still continuing with a range of stakeholders to put together an Island-wide strategy.  That includes family nursing services, G.P.s and hospice.  The outlined business case has been further developed into service specifications and will provide detail around services being delivered and monitored.  That work should come into place in the beginning of the new year.

Finally, at Huntingdon Coroner's Court earlier this year, in line with the Neuberger Review. the Coroner spared a few words of criticism for the hospital, but not for the pathway...

This is Mail Online –

The LCP, designed by the Royal Liverpool University Hospital's Marie Curie Hospice, aimed to reduce suffering in the last hours and days of a dying person's life. 

But the plan has been criticised by some experts and presented as a cost-cutting way to bring about the premature deaths of elderly patients. 

The government decided in July last year to end the LCP but in December there were reports it was simply being rebranded and not abolished. 

A Cambridge University Hospitals spokesman said: 'We recognise that although we did have discussions with the family we could have communicated more effectively, and we apologise to them for that.

And some further reading -

Liverpool Care Pathway - Long In The Making...