One in four families are not informed when doctors decide that a patient in hospital is dying under a widely used NHS scheme for palliative care, a national audit has found. Less than half of terminally ill patients and their relatives are offered religious or spiritual support in their final days and hours, while a quarter of doctors are not being trained within hospitals to deal with dying patients.
The audit, seen by The Times, comes after the NHS was accused of having a “tick-box culture” of care that defines patients as dying without questioning whether they might recover. The criticism relates to the Liverpool Care Pathway (LCP), which is endorsed by the Government and many healthcare professionals as the best way to improve treatment for dying patients with cancer or other illnesses. About 20,000 people are estimated to die each year while being cared for under the guidelines.
Under the scheme, doctors and nurses collectively agree that there is no possibility of recovery. They then remove beneficial medicines and invasive medication, such as intravenous drips. They may also sedate the patients and withhold food and drink.
However, a group of leading doctors has warned that the LCP may lead clinicians to focus too much “on the outcome of death”, when some patients might recover. Peter Millard, Emeritus Professor of Geriatrics at St George’s Hospital Medical School, University of London, among a group of doctors who have publicly criticised the LCP, said: “The risk as this is rolled out across the country is that elderly people with chronic conditions like Parkinson’s or respiratory disorders may be dismissed as ‘dying’ when they could still live for some time. If patients tell their doctors that they wish to die at home, that shouldn’t be taken as an excuse not to treat them in hospital if their condition deteriorates but they still might recover with proper care.”
The National Care of the Dying Audit found that in hospitals where the pathway was used, nearly nine out of ten patients were made comfortable in the 24 hours before death, and checked at least every four hours to make sure that they were not having medication or fluids that could do more harm than good.
But the guidance is to be updated this year to remind healthcare staff to improve communication with patients and relatives and to reassess regularly the complex decisions made at the end of life so that people can achieve a dignified and painless death.
The audit, by the Marie Curie Palliative Care Institute in Liverpool and the Royal College of Physicians, obtained details from 155 hospitals in England of the deaths of almost 4,000 patients treated on the pathway last year. Of these, 39 per cent had cancer and 61 per cent had other conditions, including pneumonia, stroke, organ failure or dementia. The average age of patients was 81, and they were cared for on the LCP for an average of 33 hours before death. The audit found that 88 per cent were prescribed drugs in anticipation of the symptoms or pain that they may develop as they neared death.
A total of 83 per cent of patients either did not need intravenous medication or fluids or had them withdrawn because they were judged to be doing more harm than good, while 37 per cent were given sedatives. Mostly these were given in low doses, but the trusts prescribing relatively high doses regularly “need to review their practice”, the audit adds. At least 40 per cent of patients were reported as being aware that they were dying, but details were not available for another 39 per cent.
Although relatives or carers were informed of the plan of care in 72 per cent of cases, and told “that the patient had entered the dying phase” in 76 per cent of cases, “there is still room for improvement”. Professor John Ellershaw, director of the Marie Curie institute, said that the pathway was used when a clinical team led by a senior doctor felt they could no longer cure a patient, but could make them more comfortable. However, the guidelines were never intended as a “one-way street” towards death and did not recommend continuous deep sedation or the withdrawal of fluids or medication. Patients should be reassessed every four hours.
Before the LCP, palliative care specialists were often called when a patient was dying, only to find relatives “confused, angry and distressed”, he added. “That three quarters of relatives and carers are now told what’s going on is encouraging, but we don’t know what’s happening in the remaining cases.” He added that patients and their carers should be offered spiritual or psychological support, for example from a priest or counsellor, if they wanted it. The audit found that a patient’s spiritual needs were reported as being assessed in only 30 per cent of cases.
End-of-life care was the cause of more than half of NHS complaints about acute hospital care between 2004 and 2006. The Marie Curie Cancer Care charity welcomed the findings but called for patients and carers to be better informed and consulted on decisions made by doctors and nurses, and said that extra funding promised by the Government for palliative care needed to be properly ring-fenced.
Jonathan Potter, director of clinical standards at the Royal College of Physicians, who was also involved in the audit, said: “Much improvement is required within busy hospital schedules for communication with and support for relatives. If we can get this right, it would make a huge difference to patients and their families.”
Joyce Robins, of the campaign group Patient Concern, said she was reassured by a new version of the pathway. “We were very concerned that the LCP had been oversimplistic, a tick-box list of symptoms to say people were dying,” she said. “But the new version is transformed and is so much better. If it is rolled out and applied properly across the NHS, there would be nowhere to hide for healthcare staff who didn’t follow it.”
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NHS to end premium-rate telephone call charges for patients
Exploiting the sick when their job is to cure them
Charges under which patients pay more than the cost of a local call from a landline are being scrapped in England after a consultation. As The Times first reported in 2007, many NHS organisations use numbers starting with an 0844 or 0845 prefix, which can be up to 30p a minute more expensive to call than a standard local number. Patients will still dial 084 numbers to get through but tariffs will be adjusted to ensure that they pay only for the cost of a local call, ministers said.
Mike O’Brien, the Health Minister, said: “We have been concerned that some people are paying more than the cost of a local-call rate to contact the NHS. For people on low incomes, and for those who need to contact their doctor or hospital regularly, these costs can soon build up. “We want to reassure the public that when they contact their GP or hospital, the cost of their call will be no more expensive than if they had dialled a normal landline number.”
A letter will be sent to NHS organisations informing them of the changes this week, while amendments will be made to GP contracts over the coming months.
Richard Vautrey, deputy chairman of the British Medical Association’s GPs committee, said: “Patients who call their surgery because they’re ill shouldn’t be penalised because they have to call an 084 number, so we’re pleased that the phone companies who supply these lines to practices have agreed to ensure that their tariffs are in line with local charges. “Combining the benefits of 084 numbers with an assurance that they won’t cost more than a local phone call is the best solution for patients and practices.”
Katherine Murphy, director of the Patients’ Association, said: “It’s great that the Department of Health has listened to patients. Asking them to pay extra costs for phone calls was unreasonable. “Patients have had to wait long enough for the ruling-let’s hope the change happens as quickly as possible.”
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20,000 British children put at risk by bureaucratic dithering over E. coli farm
Thousands of children are at risk from E. coli because the farm pinpointed as the source of an outbreak was allowed to remain open for two weeks after it first fell under suspicion. Godstone Farm, in Surrey, where children can pet and feed the animals, was finally closed at the weekend. Environmental health officials first visited it on August 28 and then again on September 3.
Twelve children under the age of 10 remained in hospital last night; three were said to be very seriously ill. A total of 36 cases have been confirmed by the Health Protection Agency (HPA) in what it said was Britain’s biggest E. coli outbreak spread by farm animals.
Up to 2,000 people, half of whom were children, visited the farm each day during the school holidays and similar numbers have visited over recent weekends.
The HPA, which said that the first known confirmed case dated from August 8, warned parents, nurseries and schools to be extra vigilant. Professor Hugh Pennington, one of Britain’s leading microbiologists, said: “The consequences of this bug can be catastrophic in young children and it can be lethal.” It was unclear when the number of cases would peak, he said, adding that there was a 12-day incubation period for this O157 strain. The professor said that the cause of the outbreak remained a puzzle. The bacteria were carried in animal faeces and could be picked up by hands, clothing and shoes. Most E. coli cases in Britain are caused by drinking contaminated water or eating infected meat.
Richard Oatway, the farm manager, defended the response yesterday. “We were told in August [that there might have been an outbreak] and we have taken the decision to close the farm [on Saturday] until the authorities have finished their investigations,” he said.
New information released by the HPA last night revealed that one person became infected with the bug after contact between visitors and the farm’s animals had been banned.
Godstone Farm’s sister premises in Epsom, Surrey, remain open. A spokesman for Horton Park Children’s Farm said that the only link between the farms was “purely financial” and there was no contact between animals.
Graham Bickler, the regional director of the HPA, said: “It is very likely that the source was animals at the farm. We know this organism is in their faeces but we need to find out how it got into the kids.” The agency defended its decision not to ask for the farm to be closed immediately, saying the scale of the problem was not immediately apparent.
Neil Wilson, an uncle of one of the sick children, said last night: “It’s been a living hell. It seems quite surreal going in and each day seeing him getting worse and worse.”
One mother who visited Godstone Farm two weeks ago said yesterday she was concerned that her 23-month-old daughter may have contracted the bug. Evelina Niedzwiedzka, 28, from Croydon, South London, said: “If the farm did know about it two weeks ago, I’m very surprised there were no warnings, especially because children are so vulnerable.”
Neil Wilson, an uncle of one of the sick children, told Sky News: “It’s been a living hell, it seems quite surreal going in and seeing him and each day seeing him getting worse and worse, feeding tubes and blood going in. It’s just awful, it’s been an absolute nightmare.”
A spokeswoman for the HPA said last night: “We have had no new cases reported today. Twelve children remain in hospital. Of those, three remain seriously ill. Six remain stable, and three children who were being looked after in paediatric units in London have recovered sufficiently to be moved to hospitals nearer their homes.”
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Australia: Woman sent home from NSW public hospital to miscarry on her own
"Alone, in shocking pain and bleeding copiously, Rose Taylor gave birth to what might have become her third child in the bathroom of her St Helen's Park home, while her husband, son and daughter slept. Despite twice visiting the emergency department of Campbelltown Hospital with obvious symptoms of a miscarriage, Mrs Taylor, 26, was not given the option of admission, but sent home on both occasions - delivering a 14-week foetus without professional support and with only paracetamol to counter excruciating labour cramps.
''It had ears, eyes, fingers,'' she said of the traumatic loss two weeks ago. ''It was a fully formed child. That's an image you don't lose. You can't just flush it away.''
Two years after Jana Horska's miscarriage in a public toilet at Royal North Shore Hospital sparked an inquiry, NSW Health has not published promised treatment protocols for women who lose an early pregnancy, so Mrs Taylor's experience cannot be measured against a standard.
Instead, a spokesman yesterday referred the Herald to guidelines issued by the Australian College of Midwives, saying they were used by area health services ''to develop local policies for the management of patients with complications in early pregnancy''. But Hannah Dahlen, a college spokeswoman, said the advice concerned basic nursing care and did not define appropriate treatment for the one in seven pregnancies that miscarry.
In October 2007 the then health minister, Reba Meagher, pledged to respond within a month to an independent report into the Horska case that recommended urgent development of care protocols for miscarrying women. The Government funded extra early pregnancy nursing positions in emergency departments, but did not commit to specific care standards.
Late yesterday the Health Department confirmed it had circulated a draft early pregnancy care policy, understood to detail circumstances in which, for example, women with pain or bleeding in early pregnancy should have an ultrasound or pathology test. A spokesman said clinicians were already using the draft recommendations - which are not available to patients - and the document would be made public this year.
Yesterday a spokesman for Sydney South West Area Health Service, which administers Campbelltown Hospital, offered sympathy to the Taylors, but said: ''Women experiencing miscarriage are not routinely admitted to hospital unless medically necessary''.
Andrew Zuschmann, from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said women in Mrs Taylor's situation should always be offered admission. ''They need access to clinical support and psychological support, and they should be in an environment where they can get that.''
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Technocracy in America
Obama neglects the real 'public option': listening to the public
The partisan and misleading speech that President Obama delivered to a joint session of Congress last week revealed the president's preferences--more government mandates, regulations, and taxes--when it comes to refashioning the American health care system. It also showcased the contempt for debate and smug sense of moral and intellectual superiority that is now as much a part of contemporary liberalism as sympathy with the nuclear freeze movement and the RainbowPUSH coalition was two decades ago.
The way the president expresses his disdain is telling. He assumes that, given the facts, any rational person would reach policy conclusions identical to his. "I have no doubt," he said, "that these reforms would greatly benefit Americans from all walks of life, as well as the economy as a whole." If only everybody had read Atul Gawande's June New Yorker article on McAllen, Texas, the president believes, then there would have been none of those rowdy town halls.
So why has the White House already missed its self-imposed deadline for reform? Why do more Americans disapprove than approve of the president's approach to health care? Why did Obama's approval rating drop steadily--among independents, precipitously--throughout the summer? The answer, he said, is "all the misinformation that's been spread over the past few months." There is no legitimate basis for opposition. There are only lies.
"Americans have grown nervous about reform," the president continued. "Prominent politicians" whose "only agenda is to kill reform at any cost" have spread "bogus claims" about his health care plan, scaring a gullible public into disapproval. For example, there is the "misunderstanding" that "federal dollars will be used to fund abortions." Some also "claim that our reform efforts would insure illegal immigrants," which is "false." And the idea that "we plan to set up panels of bureaucrats with the power to kill off senior citizens" is a "lie."
The president said that he "will continue to seek common ground in the weeks ahead," and if "you come to me with a serious set of proposals, I will be there to listen." Tell that to the Republicans who have been shut out from the legislative process on four of the five congressional committees working on health care.
"I will not waste time with those who have made the calculation that it's better politics to kill this plan than to improve it," Obama said, conveniently dismissing the widely held view that the best improvement to the Democrats' grandiose plans is to scuttle them and start over with a set of targeted insurance reforms--which could pass both houses of Congress with bipartisan majorities. No, Obama "won't stand by while the special interests use the same old tactics to keep things exactly the way they are," as if he did not already have the backing of all the special interests--the Pharmaceutical Research and Manufacturers of America, the American Association of Retired People, the American Hospital Association, Big Labor, etc. He "will not accept the status quo as a solution," as if that is what supporters of consumer-driven health care are advocating. "If you misrepresent what's in this plan," Obama said, "we will call you out."
Yet one could just as easily call out Obama for distorting the claims made against his proposals. In a world where money is fungible, Obamacare's taxpayer subsidies could indeed be used to purchase insurance plans that cover abortions. Furthermore, the president has not adequately explained how "the reforms I'm proposing would not apply to those who are here illegally" when (1) Democrats in the House Ways and Means and Energy and Commerce committees defeated amendments that would have withheld benefits from illegal aliens, (2) the president has not put forward an effective verification system of his own, and (3) who would ever tell José and Maria No mas when they show up at the emergency room in need of care?
The president was correct when he said that his proposals do not include "panels of bureaucrats with the power to kill off senior citizens." But that is not quite what the "prominent politician" was saying when she wrote,
Democratic health care proposals would lead to rationed care; that the sick, the elderly, and the disabled would suffer the most under such rationing; and that under such a system these "unproductive" members of society could face the prospect of government bureaucrats determining whether they deserve health care.
Indeed, in his speech last week Obama said himself that his plan will "eliminate" the "hundreds of billions of dollars in waste and fraud" in Medicare and "create an independent commission of doctors and medical experts"--a panel, if you will--"charged with identifying more waste in the years
ahead." It is no stretch of the imagination to think that one man's "waste" might one day turn out to be a senior citizen's preferred medical treatment.
Like it or not, Sarah Palin is making an argument about the possible tradeoffs and unintended consequences of Obamacare. Hers is an extrapolation based on an analysis of the facts. It is not a "lie," unless "lie" suddenly means "an argument with which I disagree."
By contrast, it was wishful thinking at best when the president claimed that "reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan." Politicians have been trying to clean up after the entitlement programs in such a manner since Jimmy Carter first used the phrase, but costs keep rising. This did not stop the president from ducking behind a political cliché rather than level with the public about the real price tag of universal health insurance. Obama would rather keep company with straw men than grapple with substantive criticisms.
To acknowledge that his critics act in good faith would shake the president's oversized self-confidence. He alone is in possession of the truth, the only honest broker in a den of conservative thieves, the heir to the noblest traditions of American history. In the final passage of his speech, Obama invoked the late Ted Kennedy, whose name for many people carries associations in addition to "large-heartedness" and a "concern and regard for the plight of others." Kennedy's "passion" for unreconstructed liberalism was "born not of some rigid ideology," Obama said. Rather, Kennedy knew that "sometimes government has to step in."
Now is one of those times, apparently. "This has always been the history of our progress," Obama said, raising the question of whether he believes progress is ever possible without government. The champions of progress, Obama concluded, are always "subject to scorn" and "attacked as un-American." When progress battles with reaction, he went on, "facts and reason are thrown overboard and only timidity passes for wisdom." It gets to the point where "we can no longer even engage in a civil conversation with each other." Guess who's to blame.
In recent months the characterization of Obama's opponents as a bunch of lying name-callers who do not care about facts, do not possess reason, advocate timidity and the status quo, and cannot "engage in a civil conversation" has become all too familiar. It is the natural outcome of an unstoppable force--the angry and arrogant left-wing of the Democratic party--running up against an immovable object--the instinctual conservatism of an American populace that is skeptical of complicated and expensive government interventions.
The upshot has been liberals who cavalierly demean and degrade the sentiments of the people. Liberals contemptuous of democracy and ready to embrace from-the-top, one-size-fits-all, technocratic solutions. For such liberals, the failure to obtain their policy preferences calls into question the very legitimacy of the American polity. In August, the Washington Post business columnist Steven Pearlstein--who normally tries "not to question the motives of people with whom I don't agree"--found himself, like Howard Beale, mad as hell and not gonna take it anymore: "Republican leaders and their ideological fellow-travelers," he wrote, have "become political terrorists." Last week in the New York Times, Thomas Friedman wrote that America's "one party democracy is worse" than China's "one party autocracy," because in China "one party can just impose the politically difficult but critically important policies needed to move a society forward in the 21st century." In this week's Time magazine, Joe Klein worries that "the Limbaugh- and Glenn Beck-inspired poison will spread from right-wing nutters to moderates and independents who are a necessary component of Obama's governing coalition"; after all, if the moderates and independents knew what's good for them, they'd support Obamacare.
Isn't it possible, though, that the moderates, independents, and "right-wing nutters" who traveled to congressional town halls and voiced their opposition to the president's big-government initiatives do know what's good for them--or, at least, know that Obamacare may turn out to be bad for them? That it might be too costly and too onerous for an American economy with high unemployment and staggering fiscal imbalances? That today's reform, like others in the "history of our progress," may lead to unforeseen distortions and crises down the road? Fixated on its attempt to manipulate the economy in ways that produce its desired social outcomes, the White House has neglected the only real "public option": listening to the public. Determined to pass health care reform even over the objections of popular opinion, the Democrats are practicing a hubristic and antidemocratic politics.
And they will come to regret it.
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The Truth About the Health Care Bills
By Michael Connelly, Retired attorney, Constitutional Law Instructor, Carrollton, Texas
Well, I have done it! I have read the entire text of proposed House Bill 3200: The Affordable Health Care Choices Act of 2009. I studied it with particular emphasis from my area of expertise, constitutional law. I was frankly concerned that parts of the proposed law that were being discussed might be unconstitutional. What I found was far worse than what I had heard or expected.
To begin with, much of what has been said about the law and its implications is in fact true, despite what the Democrats and the media are saying. The law does provide for rationing of health care, particularly where senior citizens and other classes of citizens are involved, free health care for illegal immigrants, free abortion services, and probably forced participation in abortions by members of the medical profession.
The Bill will also eventually force private insurance companies out of business and put everyone into a government run system. All decisions about personal health care will ultimately be made by federal bureaucrats and most of them will not be health care professionals. Hospital admissions, payments to physicians, and allocations of necessary medical devices will be strictly controlled.
However, as scary as all of that it, it just scratches the surface. In fact, I have concluded that this legislation really has no intention of providing affordable health care choices. Instead it is a convenient cover for the most massive transfer of power to the Executive Branch of government that has ever occurred, or even been contemplated. If this law or a similar one is adopted, major portions of the Constitution of the United States will effectively have been destroyed.
The first thing to go will be the masterfully crafted balance of power between the Executive, Legislative, and Judicial branches of the U.S. Government. The Congress will be transferring to the Obama Administration authority in a number of different areas over the lives of the American people and the businesses they own. The irony is that the Congress doesn’t have any authority to legislate in most of those areas to begin with. I defy anyone to read the text of the U.S. Constitution and find any authority granted to the members of Congress to regulate health care.
This legislation also provides for access by the appointees of the Obama administration of all of your personal healthcare information, your personal financial information, and the information of your employer, physician, and hospital. All of this is a direct violation of the specific provisions of the 4th Amendment to the Constitution protecting against unreasonable searches and seizures. You can also forget about the right to privacy. That will have been legislated into oblivion regardless of what the 3rd and 4th Amendments may provide.
If you decide not to have healthcare insurance or if you have private insurance that is not deemed “acceptable” to the “Health Choices Administrator” appointed by Obama there will be a tax imposed on you. It is called a “tax” instead of a fine because of the intent to avoid application of the due process clause of the 5th Amendment. However, that doesn’t work because since there is nothing in the law that allows you to contest or appeal the imposition of the tax, it is definitely depriving someone of property without the “due process of law.
So, there are three of those pesky amendments that the far left hate so much out the original ten in the Bill of Rights that are effectively nullified by this law. It doesn’t stop there though. The 9th Amendment that provides: “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people;” The 10th Amendment states: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are preserved to the States respectively, or to the people.” Under the provisions of this piece of Congressional handiwork neither the people nor the states are going to have any rights or powers at all in many areas that once were theirs to control.
I could write many more pages about this legislation, but I think you get the idea. This is not about health care; it is about seizing power and limiting rights. Article 6 of the Constitution requires the members of both houses of Congress to “be bound by oath or affirmation” to support the Constitution. If I was a member of Congress I would not be able to vote for this legislation or anything like it without feeling I was violating that sacred oath or affirmation. If I voted for it anyway I would hope the American people would hold me accountable.
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