Sunday, 28 July 2013

Liverpool Care Pathway - The Palliative Option

More excess deaths and more excess deaths and more excess deaths...
Isn't anyone joining up the dots?



This is Mail Online 


There are 600 more deaths than would have been expected in the same period.
The report said that 2013 so far "stands out as noticeably worse than any recent year"
So, what has changed?

The Standard

Isn't anyone joining up the dots?

Is the real mystery that no-one wants to see the bigger picture?

The GP 1% palliative option, downsizing care expectations is taking effect. Isn't this what was designed?

Just join up the dots.

This is their design for death.

This is become a medical holocaust...


The Independent

1,400 excess deaths at Mid Staffs...

1,600 excess deaths at Basildon and Thurrock...

United Lincolnshire plus The Dudley Group plus George Eliot plus Northern Lincolnshire and Goole plus Tameside plus Sherwood Forest plus Colchester plus Medway plus Burton plus North Cumbria plus East Lancashire plus Buckinghamshire Healthcare equals 13,000 excess deaths since 2005...

Nobody held to account, nobody disciplined...


"Excess deaths". Mostly, they didn't bother to do the paperwork on the LCP. Trusts have admitted they have no information. If they had done the paperwork, they would know. They don't know.

How many of those "excess deaths" are down to implementing the LCP?

"Excess deaths".

Healthcare Analysis & Forecasting (HCAF)

This paper documents a recurring series of infectious-like out breaks -

The above report ties in with this.

Excess deaths are mainly for those aged 85+ although the effect can be discerned above age 65, more amongst the female than the male population.

The increase in deaths is associated with a parallel increase in emergency admissions and emergency department attendances.

The paper identifies this increase in emergency admissions, the infectious-like outbreak and, therefore, the deaths as coincident and not coincidental. It is a natural linkage to make.

a) Infectious outbreak à b) Emergency admission à c) Excess deaths

However, it is worth proposing that, whilst a) may result in outcome b), it might be that c) may result from b) and not a).

In other words, the excess deaths are resulting from the emergency admission and not the infection.

The age-group fits. An out of hours admission. An A&E department under pressure. Patient written off. Candidate for LCP. How often it happens that way...

"Excess deaths".

Further reading –

Liverpool Care Pathway – Excess Deaths



"Excess deaths".

It is worth looking outside the box. And see what you can see...

Zeke's pal, Don Berwick, takes over the NHS. 

Communitarian policies going global. 

Downsize care expectations to the palliative option.

And -




The Oncology Report





































Surprise, surprise.

What's coming your way, America?

"Excess deaths"...?

Liverpool Care Pathway - A Chemical Cosh

This is surely a breach of this man's human rights. It should not be for this man's family to bring this case to court. There is a duty upon the authorities to act.


This is Mail Online 



This man was assaulted with a chemical cosh containing Lorazepam, Diazepam, Zopiclone and Tramadol. This man has a name, Mr. Peter Ryley, a 76 year old grandfather.

This took place in a British hospital.

The CEO, Peter Homa, at the Queen's Medical Centre University Hospital has apologised. He is the man in charge. He should be charged. 

Legal compensation expert Philip Needham has discussed the use of the Fatal Accidents Act in the context of the LCP.

Mr. Homa should be charged under the Fatal Accidents Act and the ECHR, signed into UK law in 1998.

The 1950 European Convention on Human Rights (ECHR) is a binding international agreement that the UK helped draft and has sought to comply with for over half a century.

ARTICLE 1


The High Contracting Parties shall secure to everyone within their jurisdiction the rights and freedoms defined in Section I of this Convention.

SECTION I

ARTICLE 2

  1. Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
  2. Deprivation of life shall not be regarded as inflicted in contravention of this article when it results from the use of force which is no more than absolutely necessary:
    • (a) in defence of any person from unlawful violence;
    • (b) in order to effect a lawful arrest or to prevent escape of a person lawfully detained;
    • (c) in action lawfully taken for the purpose of quelling a riot or insurrection.

ARTICLE 13

Everyone whose rights and freedoms as set forth in this Convention are violated shall have an effective remedy before a national authority notwithstanding that the violation has been committed by persons acting in an official capacity.


Saturday, 27 July 2013

Liverpool Care Pathway - What Have We Come To...?

When we must defend the right to life? When we must show that our life may yet be worthy of life, that we are worth fighting for, that they should not give up on us?

With the introduction of the LCP, killing has become a ‘legal’ therapy!

The concern to respect the wishes of the living and of those who wish to live has become second to that of the dying and those who wish to die.

The right to life and the desire to preserve life has been overtaken by the right to death and the desire to promote death as a preferable outcome.

The Death Cult has seized power in this land. They wish to impose the right to die and to deny the right to live. 

The Quislings have taken charge. It is their right to decide our fate. They do not admire bravery in the face of insurmountable odds. They prefer it that we just lay down and die, that we submit rather than struggle to live.

Steven Thorpe was declared brain dead. Steven’s family refused to give up. Despite four specialists maintaining there was no hope, they refused to switch off life-support and insisted on another opinion. They would not give up. That decision and persistence by Steven’s family saved his life.


Fortunately for Steven, he was just 17. Such matters do weigh in your favour when medical decisions are being taken.

In Oklahoma,
The law prohibits health care providers from making medical decisions based on the assumption that “extending the life of an elderly, disabled, or terminally ill individual (is) of lower value than extending the life of an individual who is younger, non-disabled, or not terminally ill.”  KHN

In the NHS, there is an unwritten law supporting this perspective.

The self-appointed demigods deem it their right and prerogative to make value judgements upon our quality of life.

Like little Neros, they give us the the thumbs up or the thumbs down to live or to die.

Frustrated playwrights, they will write us off, for we are but characters cast upon their page; it is for them, they say, to determine our worth and salt.

Value judgements of another's life should not be the domain of the doctor; it is not the place of medical staff – neither State appointee, nor for anyone else – to say that this is a life not worthy of life, either by comparison or degree, nor by absolute definition.

This is not the 1930s. This is not Nazi Germany. We must never go there again.

This is Liverpool Echo 

The widow of a man at the centre of a right to life battle hopes to overturn a decision that allowed doctors to withhold treatment from him.
May James, from Fazakerley, took her case to the highest court of appeal The Supreme Court of Appeal today, trying to get a previous decision over her late husband’s care torn up.
In December, Fazakerley Hospital won a case against David James’ family, giving them to right to withhold lifesaving treatments.
The dad-of-three, who was a well-known musician in Liverpool, died 10 days later of a massive heart attack.
But Mrs James has always been determined to get the decision quashed because it sets a precedent to other hospitals who can call on the decision when faced with similar disputes with families.
Speaking after day one of her two-day appeal hearing, Mrs James, 67, who had been married to her husband for more than 50 years, said: “At the moment if doctors feel that a treatment is ‘futile’ then they don’t have to give it. Not just at this hospital but all hospitals.
“I feel if I get this overturned, it’s a bit of justice for what Dave went through and what he shouldn’t have gone through. 
“I know it isn’t going to help Dave but it could help other families. This affects all of us.”

Further reading –

Liverpool Care Pathway – A Life Evaluation

Liverpool Care Pathway - In Whose "Best Interests"?

Liverpool Care Pathway – An Invasive Pathway

Liverpool Care Pathway - A Crime Has Been Committed

Liverpool Care Pathway - Obliged By Obligation!

Liverpool Care Pathway - A Human Rights Breach

Liverpool Care Pathway - And The Right To Life



The 1950 European Convention on Human Rights (ECHR) is a binding international agreement that the UK helped draft and has sought to comply with for over half a century -

ARTICLE 1

The High Contracting Parties shall secure to everyone within their jurisdiction the rights and freedoms defined in Section I of this Convention.

SECTION I

ARTICLE 2

  1. Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
  2. Deprivation of life shall not be regarded as inflicted in contravention of this article when it results from the use of force which is no more than absolutely necessary:
    • (a) in defence of any person from unlawful violence;
    • (b) in order to effect a lawful arrest or to prevent escape of a person lawfully detained;
    • (c) in action lawfully taken for the purpose of quelling a riot or insurrection.

The intentional withholding of medical treatment designed to preserve life clearly contravenes Article 2 of the ECHR.

Physicians, politicians, do not surrender so easily the right to life, for life is always precious and living matters -
"If I should ever seek death - there are several times when my progressive condition challenges me - I want to guarantee that you are there supporting my continued life and its value. The last thing I want is for you to give up on me, especially when I need you most."
- Lady Jane Campbell

       Don't Give Up

       In this proud land we grew up strong,

       We were wanted all along
       I was taught to fight, taught to win,
       I never thought I could fail
       No fight left or so it seems

       I am a man whose dreams have all deserted
       I've changed my face,
       I've changed my name
       But no-one wants you when you lose

       Don't give up
       Cos you have friends
       Don't give up,
       You're not beaten yet
       Don't give up,
       I know you can make it good

       Though I saw it all around,
       Never thought that I could be affected
       Thought that we'd be last to go,
       It is so strange the way things turn

       Drove the night toward my home
       The place that I was born, on the lakeside
       As daylight broke, I saw the earth
       The trees had burned down to the ground

       Don't give up,
       You still have us
       Don't give up,
       We don't need much of anything
       Don't give up
       Cause somewhere there's a place where we belong

       Rest your head,
       You worry too much
       It's going to be alright
       When times get rough
       You can fall back on us,
       Don't give up, please don't give up

       Got to walk out of here,
       I can't take any more
       Going to stand on that bridge,
       Keep my eyes down below
       Whatever may come
       And whatever may go

       That river's flowing,
       That river's flowing
       Moved on to another town,
       Tried hard to settle down
       For every job, so many men
       So many men no-one needs

       Don't give up
       Cos you have friends
       Don't give up,
       You're not the only one
       Don't give up,
       No reason to be ashamed

       Don't give up,
       You still have us
       Don't give up now,
       We're proud of who you are

       Don't give up,
       You know its never been easy
       Don't give up
       Cos I believe there's a place
       There's a place where we belong.

       - Kate Bush, Peter Gabriel

Liverpool Care Pathway - Is It Who You Are That Counts?

Is it really a matter of who you are whether you get heard or disregarded, whether you get listened to or not...?



Kate Granger tweeted:

"Peaceful, pain free, holding her hand and after mouthcare with sherry..."
"Now I've had a first hand personal experience of the LCP Im even more convinced it is the right way forward..."
"Gran would not have wanted us moping around. She didn't do moping. So back to work to start my new job in orthogeriatrics it is..."

George Julian replied:
GeorgeJulian ‏@GeorgeJulian
"@GrangerKate Sorry for your loss but delighted to hear of the manner of your Gran's death. She'd have been very proud of you am sure."

Kate Granger blogged:

Last Sunday I sat and held Grandma’s hand as she died. She had advanced metastatic stomach cancer and was 90 years old. Unbelievably throughout her whole illness this was the first time she had ever been admitted. She had always said she wanted to stay at home but in the end the intractable vomiting was not able to be managed adequately in the community, so an urgent admission to the hospice was arranged with Grandma’s agreement.
When I went to see her on the Saturday in the hospice she said to me “I’m not sure I should have come here.” She was really  feeling the sedating effects of the anti-emetics and analgesia, having been such a bright, cognitively intact lady and the fact that she couldn’t articulate herself properly was really frustrating her. As the over protective medical Granddaughter I reviewed her medication with the hospice doctor and agreed a non-sedating regimen of anti-emetics which I took care to explain to Grandma so she was able to understand. That was the last time we had a conversation.
The following day we received that dreaded phone call to come to the hospice as soon as we could and found Grandma comatose.
Dear Kate, I do really offer my sincerest condolences at the loss of your Grandma. She was fortunate that you could step in and review her medication to get her put on anti-emetics without a chemical cosh. It enabled you both to have one last conversation. That must have been very precious to you both.

It does help to have someone who has some influence and who will be listened to to fight your corner.

As you say, Grandma wasn’t even sure she should have gone in…

And I was surprised to read nothing about the sherry in the blog post…

You have, no doubt, read of all the families who have actually pleaded with doctors and nurses to be heard and were cruelly ignored.

So...

It was a weekend. That fits...

Why was Grandma comatose the following day?

Further reading –

Liverpool Care Pathway – This Is Inexcusable



Just to round up - some good news, Kate...?

On Twitter, the Twits have been twittering:
Katherine Sleeman @kesleeman 

"Email from Bee Wee, National Clinical director of EoL care, on ‪#‎LCP‬: A 'clear plan' is in place for development of #LCP replacement. 1/3" 
"She states 'No need for each hospital or regional group to develop its own plans.' #LCP 2/3"
"Note that email from Bee Wee sent to all members of Assoc Palliative Medicine, and I have their permission to disseminate info. 3/3 #LCP"

Bang goes that personal care plan thing...

So, if you're working on your own 'end of days' plan, Kate, you'd better make a point of getting in there first to put your name to it.

Liverpool Care Pathway - The Steps Into That Darkness Are Always Gradual, But Ever Certain

On gameboard or battlefield it is the skilled tactician who will concede the position to gain the field. The fight is not won; it is only just begun.


Opcare9, a pan-European research collaboration, received a 2.25 million euro contribution from the EU –
The main thrust of collaboration has, to date, been around the translation of the LCP into different languages and for use in different healthcare cultures. Undertaking such work has illustrated a need to understand more about the final days of life from a patient, carer and healthcare perspective in a variety of healthcare settings, in a variety of healthcare cultures.

Chairman Ellershaw spoke at the Opcare9 event. The LCP illuminati were present.

Professor Sir Howard Newby, Vice Chancellor of the University of Liverpool, said -
"OPCARE9 is about knowledge transfer - not just from the laboratory to the bedside but from one country to another.  It is vital that we continue to share our experience and expertise among European colleagues & further afield".
Following the review, where does Opcare9 stand now?

The Independent reported that the government is to "test 'end-of-life' protocols for the terminally ill after complaints from relatives".

The Independent article disclosed for public scrutiny what we already knew to be the case -
  • The Liverpool Care Pathway (LCP) has never been subjected to a proper randomised clinical trial.
  • The LCP has never been properly tested. 
  • Despite verified and verifiable and valid complaints that the LCP is a death machine - including that of a sitting member of the 'review' - the LCP has continued in use across the UK instead of being suspended - grounded - to await outcome of the 'review'. 
  • The LCP has been widely adopted throughout the world in various forms (including a 'tweaked' version in Gibraltar).

It is perfectly logical that Belgium should be the choice and Flander's killing wards the place for this study to take place. There is, after all, a history of co-operation and collaboration -

Give something a familiar and friendly handle and, already, it is halfway to being accepted. Thus, the UNBIASED study published in March 2011 -
This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands designed to explore these issues. The UNBIASED study is part of the European Association for Palliative Care Research Network [34]. The study design has been scientifically peer reviewed as part of the grant application process by the Economic and Social Research Council (UK); Fund for Scientific Research (Belgium), the Netherlands Organisation for Scientific Research and the Netherlands Organisation for Health Research and Development.
Aims of the study
• To explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice.
• To understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process.
Study settingsThe study settings include hospitals, expert palliative care units and the domestic home.

DesignThe UNBIASED study has two phases: an exploratory phase (1) and a case study phase (2). 
Threats
The threats to the successful conduct of this study relate mainly to the differing ethical review frameworks and procedures encountered in each country. We have had to make significant adjustments to the study design (especially in terms of ways of accessing deceased patients' clinical records) to comply with the strict yet somewhat different demands imposed by ethical and governance review committees in the three national contexts. These procedures specifically apply to researchers not employed as members of the clinical teams responsible for providing care to patients included in the study. This risks imposing additional costs on each national project and has created a delay in terms of commencement of fieldwork; fortunately this has been a similar experience in each country. They also introduce a possibility of bias, because the myriad of individual requirements imposed by different institutional review bodies. Considerable and continuing efforts are therefore necessary to ensure comparability of the national studies, as the study teams seek to comply with local and national requirements in the conduct of their projects.

We hope that others will be able to use this protocol to replicate the study, with necessary local adaptations, to enable further comparisons.
These are case studies taking place in the UK, Netherlands and Belgium. These are case studies of continuous sedation until death.

This study is published on BMC.

Further Reading -

The study is also published on PubMed. This follows in abstract -

The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study.


Source

End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium. Livia.Anquinet@vub.ac.be

Abstract

CONTEXT:


Existing empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K.

OBJECTIVES:

This study compares characteristics of continuous deep sedation to explain these varying frequencies.

METHODS:

In Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007-2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended.

RESULTS:

The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country.

CONCLUSION:

Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients' characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.
Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
PMID:


22652134
 
[PubMed - indexed for MEDLINE]

Publication Types

The study concludes -
Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients' characteristics or clinical profiles.
The Steps Into That Darkness Are Always Gradual

According to the University of Southampton –
Across Europe, the law surrounding end of life care has developed in significantly different ways.

For example, euthanasia (at someone's competent request) is now legally permissible in the Netherlands and in Belgium, but illegal, although subject to fierce debate and a review in the UK. 
Continuous sedation until death is being increasingly used in place of euthanasia in Flanders. Dr. Judith Rietjens says:
The use of continuous deep sedation may in some situations be a relevant alternative to the use of euthanasia for patients.
The study concludes, practitioners confirm and the statistics demonstrate that the use of continuous sedation until death has less to do with the patient's actual condition and that other factors are playing a role in the decision to embark on this course of action.

...But Ever Certain

Continuous sedation until death (also known as terminal sedation or palliative sedation) appears to be becoming an increasingly common practice. The practice is guided however, by "complex legal, cultural and organisational factors".

Sedation does produce a sense of external calm, changes hyperalert to hypoalert delerium and, since most sedation is terminal sedation, prevents patients complaining about their intractable symptoms.     - Davis MP 2009 
Continuous sedation until death is a process of imposing a 'subjective death' in which it is not possible to determine actual pain relief. The withholding of nutrition and hydration will also hasten death.

In actuality, are symptoms relieved or are relatives, onlookers, merely given that impression? The patient is unconscious in appearance, undergoing what is apparently a painless 'natural' death. There is the perception that it may be functionally equivalent to euthanasia.
Continuous sedation until death (sometimes referred to as terminal sedation or palliative sedation) is an increasingly common practice in end-of-life care. However, it raises numerous medical, ethical, emotional and legal concerns, such as the reducing or removing of consciousness (and thus potentially causing 'subjective death'), the withholding of artificial nutrition and hydration, the proportionality of the sedation to the symptoms, its adequacy in actually relieving symptoms rather than simply giving onlookers the impression that the patient is undergoing a painless 'natural' death, and the perception that it may be functionally equivalent to euthanasia. This book brings together contributions from clinicians, ethicists, lawyers and social scientists, and discusses guidelines as well as clinical, emotional and legal aspects of the practice. The chapters shine a critical spotlight on areas of concern and on the validity of the justifications given for the practice, including in particular the doctrine of double effect.Continuous Sedation at the End of Life - Cambridge.org review
Can someone please explain to me how the LCP, designed to cause death in a day or two by suppressing protective reflexes, is morally different from infusing a larger dose of sedatives designed to bring about the same end and for the same reasons in an hour or two?     -  Colin Brewer 
“Many are then put on continuous sedation so they die free of pain”

“But sedation can often mask signs of improvement, meaning doctors may be closing the door on people who would otherwise live for months”

“There is a general assumption that sedation relieves symptoms such as anxiety, delirium and pain, yet there is no published evidence to show this”
Killing with kindness? (Opioids and sedative drugs at the end of life)




Further reading -

Liverpool Care Pathway - The Dangers Which Lurk

Liverpool Care Pathway - Over Here, Over There, And Coming Your Way Soon


Liverpool Care Pathway - The Case To Answer