Liverpool Care Pathway - A Reckless Course

'Dr. Reckless' is an unfortunate name to have when committing yourself to making what can only best be described as some pretty reckless statements. Even so, in true Pythonic fashion, true life out-bests the most far fetched Monty Python sketch imaginable and produces this.

This is Oxford Mail -

Care programme for dying 'is not euthanasia'

7:00am Tuesday 29th January 2013 in NewsBy Reg Little, Oxford Times Chief Reporter. Call me on 01865 425434

Dr Bee Wee

Oxfordshire health staff have defended the use of a controversial care programme for patients who are dying.

The Liverpool Care Pathway was set up in Liverpool in the 1990s, and allows doctors to withdraw care from patients but this has led to accusations it is a “backdoor form of euthanasia”.

The pathway was introduced in Oxfordshire about three years ago and it remains in use on a number of wards at the John Radcliffe and Churchill hospitals in Oxford and the Horton Hospital in Banbury.

Care Services Mnister Norman Lamb launched a review into the nationwide service November, over concerns families were not being properly consulted on the care of their loved ones.

The results of the independent inquiry are due to be published in the summer.

Compared with other parts of the country, the Liverpool Care Pathway has not been widely used in Oxfordshire.

About 3,000 people a year die in Oxford University Hospitals NHS Trust hospitals and the trust’s Sobell House hospice, representing about half of the total number of deaths a year. The pathway was used in 209 cases in 2011/12, while nationally it is thought to be used in the deaths of 130,000 hospital patients each year.

The trust’s assistant medical director, Dr Ian Reckless, says he does not know of a single local complaint about the pathway from families or doctors within the trust.

Dr Reckless, who treats elderly patients as a geratology consultant, believes the pathway has a useful role.

It is not a treatment, he maintains – it is not something that puts people on particular drugs, deprives dying patients of food and drink or something to hasten a patient’s death.

“This is it,” he says, dropping a small folder on the table. “It’s a bundle of papers.”

The crucial thing for patients, families and the wider public to understand, Dr Reckless argues, is that the Liverpool Care Pathway is merely a framework for good practice in helping deliver the best care to patients in the last hours or days of life. In some cases that means delivering a comfortable and dignified death.

His colleague at Sobell House, Dr Bee Wee, is president of the Association of Palliative Medicine and can expect to contribute to the independent inquiry.

She said: “The Liverpool Care Pathway is really just a check list for things to consider when someone is recognised to be in the last days and last hours of life. It tells them, ‘you need to think about this’.

“The great frustration for me is that the pathway issue has diverted attention from the need to developing good palliative care.”

“This is it,” says Dr. Reckless, “It’s a bundle of papers.”

It all sounds so innocuous. A bundle of papers...

That's all the most awful of programmes ever devised in history were, a bundle of papers, a series of instructions or guidelines to follow. Of course, that's all it is. 

It is always more than just that. 

A signature, a simple flourish of loops and curves, may have monumental impact on the course of history. A 'bundle of papers' is never just a bundle of papers.

The End of Life Programme has as its purpose to identify, in an 'if the hat fits wear it' fashion, suitable candidates for the programme to gear down expectations to more readily accept palliative rather than curative options, to groom the failing in health to accept finality rather than hope.

Everywhere, in regard to the NHS, you will hear this mantra -

Affordable, Sustainable.

Community-Based Care Strategies are aiming to cut those costly hospital readmissions.

This report published this month says that "local commissioners and providers will work together to transform the local older people’s services to reduce acute admissions by one third and to redesign outpatient services to reduce volumes by around 6% per annum for three years."

"It is not a treatment," Dr. Reckless maintains in reference to the LKP (Licence to Kill People). "It is not something that puts people on particular drugs, deprives dying patients of food and drink or something to hasten a patient’s death."

Of course that is what it is.

A judgement is made that the patient is dying; a decision is taken to invoke the protocols in the bundle of papers; anticipatory prescribing is embarked upon - whether the symptom is present or not, prescribe in any case.

Here is one of your medical colleagues, sir, having a jolly time on Facebook and Twitter -

"Ellie Morys  RIP sir - you were kept alive far too long - I'm glad your suffering is at an end and I hope your family can find peace and understand that this was the best decision for you."
(LCP Clinician - posted on anti-LCP Facebook page)

"We are all dying. The question is when. And who is to say when. And who thinks they have that right to say when."

Who thinks they have that right to say when? Those who make judgements on quality of life and decide that the life not worthy or fit for life should be extinguished.

Liverpool Care Pathway - Of Gods And Men

We are all dying. The question is when. And who is to say when. And who thinks they have that right to say when.

This is Newbury Today -

Wife “broken hearted” after husband was placed on Pathway

Monday, 28th Jan 2013

Reporter: Ellis Barker Newbury News Reporter

Email: ellis.barker@newburynews.co.uk
Contact: 01635 886639

A WIDOW is demanding answers from a West Berkshire hospital, claiming she has been left heart-broken after her husband was placed on a controversial end-of-life plan without her knowledge.

Leslie Weaver, aged 89, who was one of Sir Arthur ‘Bomber’ Harris’ Bomber Command crew in World War II, was admitted to West Berkshire Community Hospital with a rash on November 9 and died just one week later.

Yet his wife, Norma, aged 78, claims the medication for his blood disorder, Myeloproliferative, a strand of Leukaemia, which he had suffered with for four years, was stopped without her consent and instead morphine was injected into his system daily.

“It’s really broken my heart,” she said. “Leslie was my darling boy, my soulmate.

“I’m not saying he wasn’t dying, I’m saying he wasn’t ready to die.

“He was a great fighter and a lover of life, he wasn’t going to give up.”

The Liverpool Care Pathway is a course of action which sees a patient’s treatment altered in the run-up to their death when it is considered that their condition has deteriorated so badly that their previous treatment may no longer be beneficial or appropriate.

However Mrs Weaver said that, due to her husband’s Christian belief’s, it was unlikely he would have agreed to be placed on the Pathway himself, but neither she nor his children gave the go-ahead for his medication to be stopped either.

She added that the fact that they had not been consulted on the change to his care meant that his children, four of whom live in Canada and two in Cornwall, had not travelled to be at his bedside.

Mr Weaver died alone on the Hayward Ward on November 16.

Desperate to get answers, she contacted Labour Member of European Parliament for the South East of England, Peter Skinner, who has contacted the hospital on her behalf.

A spokeswoman for the Berkshire Healthcare NHS Foundation Trust, Fiona Cordy, confirmed that the Pathway is used at the hospital, but said this would be discussed with the patient, their family and their GP, with consent being granted by all parties before it would proceed.

Patient confidentiality prevented her from commenting on Mr Weaver’s death, but she confirmed that an investigation had been launched.

She said: “[We] would like to offer our deepest sympathy to Mrs Weaver for her loss.

“When a patient is close to the end of life, we follow rigorous standards on how we care for the patient and how we communicate with them and their families.

“Our priority is to provide the best quality of care and to ensure the patient is as comfortable as possible at this stage.”

COMMENTS

1. 
   

   Eyes Wide Open

   January 28, 2013 10:48 am
   

   The LCP is flawed and dangerous. All my little Nan had was a skin condition (caused by a topical cream that the GP admitted was wrongly prescribed in the first place) – it was like a domino effect from there on – Nan’s skin was blistered and needed dressings which the GP recommended District Nurses for. They came to her home and befriended her, Nan loved talking to them, never imagining that they were conspiring with her GP to eventually admit her into a community hospital with no A&E, “just for 2 weeks of physio” for her legs and back which had been a little weaker – that was where they took her off her water tablets and heart medication which she’d taken for years with no ill effect, food or drink was left out of reach when they did bring it in her room, and they pumped her full of morphine, rendering her semi-comatose, they ignored her low blood pressure and let her turn blue (cyanose) due to dangerously low oxygen levels – 3 days of this was all her little body could take. Yet, they get away with it! How? I will never trust them again – why didn’t they leave my Nan at home, somewhere she was happy and where my Dad took pleasure in helping her in any way he could after all she had done for him, for the family, for others and for her country during the war – how dare they!

   
   
2. 
   

   ogrizek

   January 28, 2013 1:05 pm
   

   I have written about my experiences in Canada. I signed a DNR four years ago for my mother. I did so at the urging of hospital staff. My mother recovered and is still alive today. Predicting death is very difficult and I think a lot of doctors and nurses are a bit trigger-happy.
   Here is my article: http://ireneogrizek.ca/2012/12/28/5762-the-right-to-choose-life-or-death/

   
   
3. 
   

   sunny

   January 28, 2013 3:08 pm
   

   The standard of care seems to be going downhill . This poor woman …. I feel for her . I hope she gets some answers ! I think it is disgraceful that her husband did not get the medication he needed

   
   

Liverpool Care Pathway - The Sneak In The Waiting Room

2013

Lunar New Year falls this year on February 10 which will inaugurate the Chinese year of the Snake.

2013 also inaugurates the CQUIN year of Dementia.

Healthcare professionals are being tasked to identify early signs of dementia. 

They have to be found so they can be helped... on their way.

Discussing the validity of hydration and nutrition, this is the British Medical Journal -

Dutch research reflects problems with the Liverpool care pathway

ASSESSING DYING

12 May 2008

With 30 years' experience as a geriatrician, I always found it difficult to predict death, which is what is being sought here, in order to implement the LCP appropriately. While the LPC offers useful guidelines on the management of end-of-life symptoms, it seems to be rushing in with sedation and opiates without considering whether hydration and nutrition are also still valid treatment.

Competing interests: None declared

Competing interests: None declared

Bruno Bubna-Kasteliz, Professional Adviser

Office of Health Ombudsman, Millbank, London W1P 4QP

Discussing the validity of hydration and nutrition, this is a comment left on these pages referencing a BMJ article -

1. 
   Harlow blogger26 January 2013 13:08

   The following is from a study carried out in a nursing home in Holland for people with dementia:
   
   
   "Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study."
   
   BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7376.1326 (Published 7 December 2002)
   Cite this as: BMJ 2002;325:1326
   
   "The amazing recovery of Mrs R"
   
   "Mrs R, 81 years old, arrived at the nursing home in a bad state. After admission she deteriorated. She weighed less than 40 kg and was dehydrated. “In a dreadful state” was how the nursing staff described her. After discussing it with the family, doctor M decided to perform hypodermoclysis in both of Mrs R's legs.
   
   Doctor M: This caused tremendous opposition from the nursing staff. However could I think of artificially administrating fluids to a woman in that state? I really had to do my best to explain that I also have my medical responsibilities and had to try it. I must honestly admit that I, too, didn't have much hope. Well, that was three years ago, and if you see Mrs R now, would you ever imagine that she had been so far gone then? She's made a wonderful recovery. She walks around the ward all day long tidying up and really is the sunshine in house. I use the example of Mrs R whenever the nurses protest about hypodermoclysis."
   
   In the case of patients with dementia, hypodermoclysis is often done at night, while the patient sleeps, as this overcomes the problem of such patients pulling out the tubes used.
   
   

The June 2010 Macmillan End of Life Care Newsletter shares the National End of Life Care Programme logo and is published by NHS. This really is getting like a medical-palliative-pharmaceutical version of Ike's 'military-industrial complex'.

Mr. Lamb has said he is 'uncomfortable' with the word Pathway. The use of the word 'programme', however, is both worrying and problematical to anyone who has the slightest knowledge of the 1930s' end of life programmes and the horrific events which culminated in what became known as the Holocaust.

The Newsletter describes a new e-learning package for End of Life Care -

"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"

We are talking about someone dying.

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

Dr. Bee Wee certainly seems to be 'having fun' in this photo-shoot picture from the Newsletter.

Were these 'fun' lessons devised by the same team that devised that infamous 'mission impossible' slide -

They have been discussing a document to put someone, a year hence, onto The Death Pathway, a Communitarian version of the Final Solution.

Then comes the final slide.

Which is supposed to extort a chuckle from the gathered throng of healthcare professionals who haven't already dozed off!

This is sick...

According to a LCP Symptom Control Algorithm chart, Medicines for symptom control will only be given  when needed, following an assessment, and at the right time and just enough and no more than is needed to relieve the symptom.

Anticipatory prescribing is recommended - whether the symptom is present or not, prescribe in any case - but it is given prn, as required. 

In the Newsletter, the Macmillan GPs are rather more gung ho - "Good pain relief requires regular dosing rather than a vague direction 'as required'."

If there is not consensus on what are the LCP protocols how can there be meaningful training?

Meanwhile, the National Council for Palliative Care is going gung ho in discussions with NICE on the use of strong opioids.

From the NCPC Report and Financial Statements 31 March 2012 -

There were two significant NICE consultations during the year, on an End of Life Care Quality Standard and on the use of strong opioids. Our consultation responses were informed by extensive feedback from our working groups as well as by people with personal experience of end of life care,and many of our key recommendations were accepted.

End of life discussion is intended to gear down expectation. End of life discussion is intended to gear down perception to see the cup half empty rather than half full. End of life discussion is intended to gear the mind into seeing dying as a positive life option and to perceive the moment to be gone.

From the Newsletter - "Discuss with family and friends how to get care and help at different times. Specifically advise that calling 999 is very seldom appropriate and may result in resuscitation, transfer and admission."

We don't want those readmissions; they cost money.

Liverpool Care Pathway - Playing With Lives

A proportion of funding is withheld and paid on condition that targets are met. It is pure semantics to argue that the CQUINs which will restore the shortfall withheld, and more besides, are anything other than exactly what they are - incentives.

Putting those targets in place is playing with lives.

This is Lynn News -

Sunday 27 January 2013
KING’S LYNN: Hospital chiefs reject pathway cash ‘bonus’ claim
Published on Saturday 26 January 2013 09:30

Hospital chiefs say a payment relating to the use of a controversial palliative care treatment was not an “incentive”.

Lynn’s Queen Elizabeth Hospital received £225,000 Commissioning for Quality and Innovation (CQUINS) money from the primary care trust or the Liverpool Care Pathway in 2011 and 2012.

The pathway was developed to help terminally ill patients by withdrawing treatment but it has recently come under fire.

Director of patient experience Gwyneth Wilson said the hospital received the money for its quality of care.

The payment included the costs associated with recruiting additional specialist staff to train nursing and medical teams in the appropriate use of the treatment plan and development of an associated administration system.

Ms Wilson said: “The payment is made on the condition that we have achieved an agreed level of quality in our standards of care. It is categorically not an incentive payment for identifying patients to commence end of life care.

“The Liverpool Care Pathway is a nationally-agreed standard for end of life care devised by hospices. It allows acute hospitals to offer the same high level of care that patients with a terminal illness would expect if they chose to spend their final days in a hospice.

“Introducing the LCP in our trust involved recruitment of two specialist nurses who were then able to introduce an extensive training programme for doctors and nurses throughout the trust.”

The CQUINS system introduced in 2009 to make a proportion of hospital’s income conditional on demonstrating improvements in quality and innovation in specified areas of care.

2 comments

Olly Beak

3:30 PM on 26/01/2013

They used the pathway on my brother who went home to his family after we intervened. He died over a month later and I have been waiting since August for a reponse to the letter I sent them concerning the event. If they were paid for the level of care they devolved in his case they would not recieve a penny. The whole system is open to abuse amd nisinterpretation.

violetkathy

2:42 PM on 26/01/2013

It's a shame the extensive training programme wasn't up to scratch then isn't it? My brother was on the LCP and unconscious until I arrived at the hospital and started to give him fluids and he regained consciousness. The LCP is a deeply flawed method of delivering care. There is no way to scientifically predict death and fluids should never be withheld from patients just because they are presumed to be at the end of their life.

Liverpool Care Pathway - Playing With Words

Glyn Davies, MP, writes from Rural Wales about the inquiry and Baroness Neuberger.

"She is on record of being supportive of the Liverpool Care Pathway," says Mr. Davies. That does not preclude her appointment. The review is not into the LCP but into how it is put into practice. What a game of semantics. They're playing with words whilst, back on the wards, they're still playing with lives.

Saturday, January 26, 2013

More on Liverpool Care Pathway.

A few weeks ago I instigated a debate in the House of Commons on the Liverpool Care Pathway. The gist of the speech with which I opened the debate was that in general, I support the principle of transferring the commitment to palliative care typical of hospices to hospitals and other forms of care - but that the Pathway must be implemented strictly in accordance with the principles on which is has been established. There seems to be much evidence that this has not always been the case. I asked that the Gov't thoroughly investigate recent publicity about patients being placed on the Pathway without consultation with them or their next of kin. This is not acceptable. There are also reports of other departures from proper procedures. A line which grabbed public attention and summed up my approach was that "we shouldn't scrap the LCP - we wouldn't scrap the Highway Code because there are some bad drivers on our roads".

Since the debate, the Gov't has appointed former Lib Dem peer, Baroness Neuberger to chair an independent inquiry. She is on record of being supportive of the Liverpool Care Pathway, but there is no reason to think she will not be thorough and objective. She will have read comments in yesterday's Telegraph by her former Lib Dem colleague, Lord Carlile of Berriew, which offer her some strongly worded advice. On this sort of issue, I usually agree with Lord Carlile.

While I do not disagree at a fundamental level with anything Alex Carlile is reported to have said, there is no doubt that the tone of his comments take him further than I went. He calls for the Liverpool Care Pathway to be replaced, and to be given a different name. I would support that if Baroness Neuberger recommended it, though my view is that the problems arise from the Pathway not being followed as it should be, rather than the Pathway itself. I do agree that 'Pathway' seem to me to be a particularly unfortunate name though. Alex is also reported to be calling for doctors who put patients on the LCP without telling next of kin to be reprimanded by the General Medical Council, even 'struck off'. Personally, I feel that continuing with regular checks every few hours to make certain that patients have not rallied enough to be taken off the Pathway is another crucial part of proper palliative care. Whatever, Its clear there's much uneasiness about how the Liverpool Care Pathway is being implemented, and we need the independent report delivered to Secretary of State for Health as soon as possible.

Liverpool Care Pathway - Raising Concerns

This is Irene Ogrizek –

"Hello, I have written about a similar problem in Canada. However, in this country, there is no recognized pathway and so our struggle is more difficult: it is hard to point fingers at something that we're being told doesn't actually exist. I have a series of articles I wrote about this problem. If you would like to read one of them, here is the link: http://ireneogrizek.ca/2012/12/28/5762-the-right-to-choose-life-or-death/"

 Irene's article highlights these major problems -

1. Timing: As Dr. Patrick Pullicino states, in his critique of the LCP, “Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically.” It is also subjective. On the advice of doctors at my mother’s acute-care hospital, I signed a DNR for her in October, 2008. It is now December of 2012 and she is still alive. Another example: an elderly man Dr. Pullicino pulled off the LCP recovered enough so that he was able to return home. The 71 year-old had been admitted for pneumonia; another bout with it landed him in hospital 14 months later, at which time he was again put on the LCP. He was dead five hours later.
2. Lack of consultation with families: Dr. Margaret Cottle, a palliative care doctor from BC, stated that in an article published in the Canadian Medical Association Journal, a confidential study showed that a full 32% of 208 Belgian doctors had performed assisted suicide without the knowledge or consent of the families of patients. A further 20% had euthanized patients without the patient’s consent. They felt that to have that conversation – like the conversation I had with my mother – would stress the terminal patients too much. It was simpler, instead, to euthanize. The same lack of consultation is a problem in the UK. It was the families of patients, for example, who raised the initial alarm about LCP; they did so when they realized loved ones had been put on the pathway, also without their consent.
3. Creating the conditions and premature deployment: In part 1 of this article, I wrote about Diana Ford’s struggle to keep her father alive. Like Rodriguez, she is also taking her case to court, via the Ontario Appeals Board. Her argument? Many doctors habitually under-treat the elderly, allowing dangerous conditions and diseases to worsen. By doing so, they are creating favourable conditions for a protocol like the LCP. In my mother’s case, her symptoms of diminishing circulation, and then her gangrene, were treated as if she were on a slow boat to China. Although gangrene is potentially fatal, there was no urgency in her treatment that I could detect. As Patrick Pullicino has noted: “Very likely many elderly patients who could live substantially longer are being killed by the LCP.” Why? Because it’s the elderly that are particularly susceptible to the deployment of these
   
   

   My mother and her loving caregivers, Vivian, Shannon and Lucy
   passive, let-nature-take-its-course strategies. It’s hard to imagine a doctor allowing a 32 year-old, with symptoms similar to my mother’s, being treated in quite the same way.
4. The use of funding to promote the LCP: In England, reporters using the Freedom of Information Act discovered that hospitals that met quotas for putting patients on the LCP received significant financial rewards. Hospitals that failed to meet those quotas were heavily penalized. (One source of one hospital’s funding was halved when they didn’t hit their “target” numbers.) This creates a top-down incentive: administrators are motivated to look the other way when the LCP is abused. They do so to maintain high funding levels and to keep their jobs.
5. Incapacitated patients may be abused: Not all sons and daughters are capable of taking care of their parents. Not all relatives or people who have power-of-attorney are honest. They may support the hastened death of an elderly relative or ward because they stand to gain financially. Again, this is a particular risk for older patients: most younger patients haven’t had the chance to accumulate wealth and most of them, like Sue Rodriguez for example, are of sound mind. The elderly are more likely to have significant assets and are also more likely to suffer from conditions which interfere with their decision-making. Easy access to the LCP may aid unscrupulous legatees.
   
   These issues are not reasons to withhold a treatment like the LCP from everyone. For patients who are discernibly close to death, and who are in extraordinary pain, the LCP is humane if it is what they choose. The problem, of course, is creating a decision-making protocol to protect those most vulnerable to its abuses. The elderly are far more likely to be hastened towards death, as their deaths seem imminent and inevitable anyway.
   
   In conclusion, we need to hold families and doctors accountable when the decision is made to end a life. Mandates for care have to be explicit and difficult conversations have to happen. The LCP pocket guide, the link to which I am providing below, is shamefully vague. As someone who teaches young people, and insists they express themselves clearly, I read this pamphlet with dismay: it is one of the worst examples of weasel-wording I’ve ever seen.

Liverpool Care Pathway - Dangerous And Deadly

A reader writes to the Southern Daily Echo from Southampton -

• Daily Echo »
 
• Your Say »
 
• Readers' Letters »

READERS' LETTERS

Is hospital still using Pathway scheme?

6:21pm Tuesday 22nd January 2013 in Readers' Letters

THE excellent Echo report on the Liverpool Care Pathway (LCP) programme highlighted some very serious issues for its supporters and critics like me.

The recent news by the Quality Care Commission stated that the Southampton General Hospital’s (SGH) administration is not fit for purpose, or safe to meet patients’ health and welfare needs combined with the Government’s health minister Norman Lamb in Parliament stating the Pathway care programme and its guidelines has “become a distortion of what it should be about”.

The Government has now started an independent review of all LCP policies and procedures led by the respected Baroness Neuberger and will publish results and recommendations in the summer of 2013.

Having failed to get any answers from management administration of SGH, although I do realise they are busy, struggling to make the hospital fit to provide basic medical care, can I use the people power the Daily Echo seems to give us in our city to get the SGH management to confirm if any care Pathway terminations are still being carried out, as I feel it would be irresponsible to ask the dedicated clinical, nursing and care workers to carry out these procedures until the full results of the review are published.

The issue this reader highlights is perfectly valid whether you consider the vehicle, the driver, or both to be not fit for purpose. In a situation where the Hospital Administration itself has been found not fit for purpose, it would be surely most irresponsible, dangerous and deadly if the Death Pathway were still in operation.