Politics: The Liverpool Care Pathway and End of Life Care in the NHS

The Liverpool Care Pathway and End of Life Care in the NHS

The way in which the NHS and Hospice’s look after terminally ill patients has faced much criticism in recent months. In particular the Liverpool Care Pathway has been the main victim of the majority of this criticism being branded as “a license to kill” by the Daily Mirror and the tabloid press.

So what exactly is the Liverpool Care Pathway?

    The Liverpool Care Pathway is a framework for end of life care in the NHS. To be placed on the Liverpool Care Pathway the medical team of the dying patient, including a senior doctor, must recognise signs that a patient is close to death. If a decision is made to place the patient on the LCP, all medical treatments, which do not alleviate their suffering and are deemed no longer of benefit to the patient are withdrawn. This frequently involves the removal of I.V. drips, although patients are still encouraged to ingest food and water orally whilst on the pathway as this is considered nursing care rather than medical intervention. 

     The pathway aims to provide a form of hospice care inside a hospital environment to prevent unnecessary suffering in the patient’s final hours. It is estimated that around 130,000 patients who die in hospital per year are on the Liverpool Care Pathway, therefore making up around 29% of the total number of deaths inside hospitals each year. The medical profession’s view of the Liverpool Care Pathway is that it is an extension of one of the NHS’s key principles granting patients autonomy over their own care. However, recent failings in the use of the Care Pathway, most notably doctors failures to secure the necessary consent from patients needed to be placed on the Care Pathway warrants debate as to the appropriateness and the effectiveness of the supposed best practice and its use in the NHS.

     

Controversy

        The first major criticism of the LCP is that doctors have no objective, or 'tick box' way of determining death in a patient. As a result it seems counterintuitive to withhold a patients medication when they may have months or even years of life left ahead of them. However it is important to realise that sufferers of certain medical conditions experience similar trends in the decline of their function. Contrary to popular opinion death from cancer is relatively easy to predict due to the very sudden and rapid decline in a patients health. Similarly, the decline in a patients health from lung or cardiac failure, whilst occurring over up to 5 years also experience a fairly rapid decline with noticeable symptoms over just a few short months, although intermittent declines in health may result in some time in hospital. In contrast death from dementia or frailty is substantially more difficult to predict. For this reason patients are monitored prior to being placed onto the pathway and then monitored to an even greater extent afterwards in order to reduce the chance of an incorrect diagnosis. Patients should only be placed on the LCP when within one or two weeks of death.

       

      To be placed onto the Liverpool Care Pathway there is a moral obligation on the part of to doctors acquire the permission of the patient or of a competent family member. However, although doctors have a moral obligation to ask for permission, Marie Curie states that “the LCP is not a treatment but a framework for good practice, therefore, written consent is not required” but details that plans “SHOULD be discussed with the patient where possible and deemed appropriate and ALWAYS with the relative or carer”. However, it is estimated 65,000 patients a year are placed on the Liverpool Care Pathway without their consent being given. Such figures are shocking. However, many supporters of the LCP argue that it is not the failing of the concept behind the LCP in these matters but that of the hospital providing the care. In the words of the BMJ, in practice “the LCP can only be as effective as the clinicians who provide it”. 

    Sadly, the knock-on effect of the tabloid press’ rhetoric attacking the LCP has lead to a marked drop in the number of patients consenting to being placed on the LCP and has created a PR scandal in the NHS. This is despite evidence increasingly demonstrating that the hospice care which the LCP aims to provide, is superior to more traditional methods of end of life care. In the recent VOICES survey (the only current national survey performed) 96% of individuals experienced pain when dying. However, over 60% of patients in hospices found such pain completely relieved as opposed to only 33% in hospitals. 

    As a result of  public backlash against the LCP and following a six month independent review, the government has decided to phase out the LCP over the next 6-12 months. The LCP is to be replaced by"individualised care plans and condition specific guidance" under recommendation of the review panel. This is because although the review panel and numerous nursing and medical professional bodies acknowledge that the LCP can be used to provide a model of best practice too many patients have received poor care as a result of failings in the implementation of the Care Pathway.

-Adam

Politics: Mid-Staffordshire Hospital Scandal

NHS: Mid-Staffordshire Hospital Scandal

     

      Described as the NHS's "darkest day" the recent publication of Robert Francis's damning report of his thirty-one month long public enquiry has catalysed a return of the Mid Staffordshire NHS Trust scandal to re-emerge at the forefront of the public consciousness. Francis's scathing report has revealed "shocking" failings in the care provided by the Stafford Hospital, which is believed to have led to the unnecessary deaths of between 400-1200 patients. Failings in the standard of care provided by the hospital is believed to have been caused, primarily, by the hospital's cost-cutting in pursuit of foundation trust status. 

       Although concerns surrounding the Stafford Hospital's unusually high mortality rates in 'emergency' cases was first recognised in mid-2007 it is believed the hospitals decline in quality of care provided began to manifest in early 2006. By January 2008 the HealthCare Commission (HCC), a healthcare watchdog, and its developing suspicions were fuelled by the triggering of several patient safety alerts at Stafford Hospital. The first warning signs of problems at the trust. The hospitals explanation to the HCC, that such figures had been 'coding errors', did not hold water with the HCC. The HCC assigned Heather Woods the task of launching the first of five enquiries into the hospital and the standard of care it was providing. 

Robert Francis, QC

      The ensuing investigation uncovered what it described as "appalling" care at the Stafford Hospital. Staff were inadequately trained and too few in number, junior doctors were left unsupervised and forced to administer care beyond their experience and receptionists with no medical training were required to assess the urgency of cases entering A&E. The Francis investigation detailed how patients were left “unwashed, unfed and without water” while staff treated them and their relatives with “callous indifference”. The firsthand accounts of many of the hospitals former patients formed the basis of Francis's investigation which details a culture where “the most basic standards of care were not observed".The enquiry further placed the blame principally on "A chronic shortage of staff, particularly nursing staff, [which] was largely responsible for the substandard care." The resulting pressures on remaining staff led to a deterioration in morale and to many staff exhibiting a "disturbing lack of compassion towards their patients". The enquiry also placed a significant amount of blame on the trust's ruling board and their decision to attempt to save £10 million pounds between 2006-2007 in their bid to obtain foundation trust status by jeopardising the standard of care their institution provided. 

      Almost every level in the NHS's chain of monitoring and regulation had failed in some aspect of their role in order for the substandard care at Stafford Hospital to go unnoticed for such an extended period of time. All political and medical bodies agree that the Mid-Staffordshire Hospital scandal must never be allowed to happen again. Indeed, the publication of the new Francis report will outline measures in order to ensure that such a failing in the NHS's system of care is prevented. MP's and other NHS representatives have already begun debates as to what such safeguards should consist of. A legal minimum of staffing levels on NHS wards, a legally-binding "duty of candour" on all NHS staff to admit to mistakes and a blacklist of failed NHS managers are just some of the measures being considered in the wake of the Francis report. However, with the governments commitment to secure £20 billion in efficiency savings, it would be idealistic to believe this will not have severe repercussions in front line care hospitals provide. Parallels can be drawn between the £20 billion pounds in cuts to the NHS budget and Stafford Hospital's attempts to save £10 million in funds, which played a significant role in facilitating a decline in the quality of care provided at the hospital. This raises a significant question. How can the NHS be expected to maintain exemplary standards of care with further cuts to its budget increasingly likely in the future? 

-Adam

Science - Cancer and the Push towards Personalised Treatments

Cancer - The Push towards Personalised Treatments

         Whereas previously cancers were defined by their position inside the body, advances in the field of oncology are increasingly revealing that primarily similarity between cancers is as a result of similar genetic mutations different cancers may cause. This means that a particular lung cancer may have more in common with a specific breast cancer than another type of lung cancer. This has profound repurcussions in the medical field where currently treatments are prescribed by a clinician based primarily upon the severity and location of the cancer in the body. However, with each cancer having the possibility of causing over 100,000 genetic mutations inside cancerous cells current genetic sequencing equipment is, at present, insufficient in terms of efficiency and economic viability to be used to sequence the DNA of the UK's many thousands of cancer patients. The reason for these problems with the equipments efficiency in coding a patients genetic code becomes clear once it is realised that storing one million cancer patients genetic codes would require as much space as Youtube.

        The Institute of Cancer Research (ICR) is pouring funding into new projects designed to provide greater insight into which mutations cause tumour suppressor genes to lose function. If tumour suppressor genes become inactivated they can no longer inhibit cell proliferation leading to uncontrollable cell growth and the formation of a tumour. By understanding which mutations cause healthy cells to convert into cancerous cells it is hoped that improved treatments specific to an individuals own particular type of cancer. Rapid advances in genetic sequencing techniques are catalysing this progression towards personalised treatments. One of the most established of these new 'personalised' treatments is the drug Herceptin. Herceptin is already being used to treat certain types of breast and stomach cancers in which the protein HER2, which stimulates cell division, is over expressed. However, such treatment is immensely expensive costing over £65,000 ($100,000) for a years treatment of Herceptin resulting in numerous American insurance companies and the NHS in Britain being reluctant to prescribe such treatments. Despite the expense of such treatments the ICR is hopeful of improvements in genetic sequencing and the development of new drugs reducing the costs.

        However, treatments specific to particular mutations (in what are rapidly proliferating and mutating cancerous cells) are then face with the problem of tumours developing resistance. Prof. Alan Ashworth, the ICR's director, has detailed the disappointment he feels when promising new drugs failing after the cancer develops resistance after only a few months. Describing the ICR's battle against cancer as a "bit like the game whack-a-mole" with the re-emergence of a cancer after it has seemingly been eradicated by a new treatment. The Tumour Profiling Unit at the ICR is understood to be planning to undertake a programme of frequent testing of cancer sample in order to understand changes the tumour undergoes in order to achieve such resistance. 

    Newly unveiled government plans to record the entire genetic sequences of over 100,000 patients with cancers and rare diseases clearly shows the governments commitment to stimulating progress towards more personalised treatments. The potential benefits of such plans to researchers is significant and scientists are already predicting implementation of new, faster genetic sequencing techniques into the NHS within the next 10-15 years.

-Adam