Wednesday, 8 January 2014

Liverpool Care Pathway - An Awayday On The BMJ...

The LCP is an evidence-based document used to guide the care of dying adult patients, while providing measurable outcomes of care (Ellershaw et al, 2001)

This is Des Spence in the BMJ –
Evidence based medicine (EBM) wrong footed the drug industry for a while in the 1990s. We could fend off the army of pharmaceutical representatives because often their promotional material was devoid of evidence. But the drug industry came to realise that EBM was an opportunity rather than a threat. Research, especially when published in a prestigious journal, was worth more than thousands of sales representatives. Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment. 
You see, without so called “evidence” there is no seat at the guideline table. This is the fundamental “commissioning bias,” the elephant in the room, because the drug industry controls and funds most research. So the drug industry and EBM have set about legitimising illegitimate diagnoses and then widening drug indications, and now doctors can prescribe a pill for every ill. The billion prescriptions a year in England in 2012, up 66% in one decade,2 do not reflect a true increased burden of illness nor an ageing population, just polypharmacy supposedly based on evidence. The drug industry’s corporate mission is to make us all sick however well we feel. As for EBM screening programmes, these are the combine harvester of wellbeing, producing bails of overdiagnosis and misery. 
Corruption in clinical research is sponsored by billion dollar marketing razzmatazz and promotion passed off as postgraduate education. By contrast, the disorganised protesters have but placards and a couple of felt tip pens to promote their message, and no one wants to listen to tiresome naysayers anyway. 
How many people care that the research pond is polluted, with fraud, sham diagnosis, short term data, poor regulation, surrogate ends, questionnaires that can’t be validated, and statistically significant but clinically irrelevant outcomes? Medical experts who should be providing oversight are on the take. Even the National Institute for Health and Care Excellence and the Cochrane Collaboration do not exclude authors with conflicts of interest, who therefore have predetermined agendas. The current incarnation of EBM is corrupted, let down by academics and regulators alike. 
What do we do? We must first recognise that we have a problem. Research should focus on what we don’t know. We should study the natural history of disease, research non-drug based interventions, question diagnostic criteria, tighten the definition of competing interests, and research the actual long term benefits of drugs while promoting intellectual scepticism. If we don’t tackle the flaws of EBM there will be a disaster, but I fear it will take a disaster before anyone will listen. 
Cite this as: BMJ 2014;348:g22 
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.Provenance and peer review: Commissioned; not externally peer reviewed.
  • EBM took off in the 1990's. So did the LCP...
Spence supports the LCP and has commented that the pathway
"must be used with full explanation and the consent of all involved. If it has not been used in this way, then a review is welcome if only to reassure the public."
The public were not reassured. The sheer weight of evidence forced the Review to suspend the LCP in England. It is also now being withdrawn in Scotland. Even so, Spence must be fully aware that the pathways are legion and live on.

Will Spence act on promoting the prosecution of those responsible for 'misapplying' the LCP? Will he act with immediate determination, for instance, to get Dr. Alison Coackley removed from the Medical Register and seek a charge of murder - at the very least, manslaughter - against her?

Read further here -
Liverpool Care Pathway - These Disgusting People
Liverpool Care Pathway - Onward And Upward

The BMJ’s own Dr. Tessa Richards also writes -
Ten years ago a friend suggested that I write up my experience of weathering emergency thoraco-abdominal surgery for adrenal cancer. “It will be a useful cathartic exercise,” she said. So I did, and maybe it was, but I didn’t share the story. Skilled care saved my life. Might any critical comment be seen as carping rather than constructive? 
Now the value of collecting and learning from patients’ accounts of their experience of illness and care is well established and enshrined in policy, notably the UK Health and Social Care Act 2012. It’s widely seen as an essential tool to monitor and drive up the quality of care and to improve the delivery of services and the experience of patients who use them. 

Yet despite “patient-centric” policy commitments and an obligation stemming from the Francis report into failings at Mid Staffordshire to listen, learn, and respond to the view of patients and carers, the gap between policy and practice still yawns. Swathes of information are being collected from patients, but most is not being systematically analysed in a timely way and used to inform change. And the patients who supply it get little feedback. Experts in patient experience data argue that substantive investment is needed in the science of gathering and using it.
The PROMs are just a box-ticking exercise that means little or nothing but cited as documented consultation. And as for the Patients on the death pathways, they cannot respond upon their experience for they are dead.

"Hell - I sound like a Daily
Mail reader...!"- NHS Forums
Dr. Tessa Richards has documented her own experiences as a patient and these are recorded in the pages of the BMJ. She comments in "Journey of a Patient Editor" -
Compartmentalised care is tough on patients
I remembered a debate held at the Royal College of Nursing on whether washing patients is part of a nurse’s duty or not. The majority concluded it was. But the fact that it was questioned had surprised me. Recognising different skill sets is important, but for a patient the idea that personal care should be compartmentalised, with the less desirable bits delegated to the lowest in the pecking order, seemed odd. 
But compartmentalisation is where we are at. In my last clinical job in a rheumatology department I saw many elderly patients with multiple intractable problems being passed like parcels between different specialists. The difficulty of seeing the whole picture, especially when notes and x ray pictures are missing, is huge. Patients get frustrated, upset, and confused, not least about who “their” doctor is. 

It’s hard to quantify the effect of continuity of care, holistic management, and the simple interventions and humane acts that make being a patient tolerable, but we should surely appreciate their value more and reward those who provide it. The kindness of two medical students who sat on my bed and talked to me as if I was a sentient being will long stay with me.
- Mail Omline
A Rapid Response from Dr. Philip Harrison of Wellington, New Zealand follows -

Although I am personally familiar with Dr Richard's struggle through the illness she describes, this is a remarkable chronicle of personal experience through the healthcare system. As a GP I am sad so little of her experience came from primary care where I am situated in NZ. Her journey should have started earlier and in a kinder place so that she could return and be supported by those who knew her well. I see my own patients suffering similarly and I realise that I must make a greater effort to attend them - and spend a little time - when they are incarcerated in such institutions and traumatised by their interventions. This week 2 patients of mine died in extremis and I was too busy to attend them in hospital. 
Sadly, I also see the demise of 'real' nursing - Tessa does not address this head on in fear of offending - where the ownership of qualifications and ability to put in iv lines out trumps the caring that patients need. I see this space occupied by carers, usually nurses qualified from overseas who cannot get employment due to the regulations we create. It is the carers now who wash one's private parts, comfort the distressed elderly lady with a wet nightie, tell them not to worry, feed people who can barely swallow, pray for them (they are often religious) and generally attend to their needs. They do what nurses used to do. Where are our own people and where is our caring? Of course, doing other jobs because of better pay. Somehow the price of compassion has been lost in the NHS and probably across many other healthcare systems in a morass of targets, pathways and deliverables. 
This article should be given to every medical students and trainee nurse to help them understand why we are here. Giving it to politicians, could be also be productive but likely to end up, alas, in the too are basket. Small compensation to me that I get a huge 15 minutes in primary care to see my NZ patients but I still struggle to keep on time knowing that everyone really needs to talk, be cared for, reveal something they didn't attend to discuss, and get to know me so one day they might pour out their hearts like the doctor friend I should be, but rarely am. 
Competing interests: None declared

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