Posted by: Witch Doctor | August 29, 2010

The Tools of the Trade


You are still looking a bit perplexed, My Black Cat……

You are wondering what “tools” are…….

You know perfectly well what tools are, My Black Cat. You will find an abundance of tools in all shapes and sizes in the garden shed. Spades, forks, trowels, dibbers, lawnmowers, rakes, hedge clippers are all tools. In the same way you’ll find tools in The Spell Pantry although maybe the word “utensils” better describes what you will find there.

Why are you appearing to be so stupid?

There is a tool thing being used in hospitals to help patients on their way.

Ah, My Black Cat, I can understand how you are perplexed. It now seems they are using a “tool” to help patients get discharged home…..

The Witch doctor first came across the meaning of the word “tool” in the hospital context many years ago. It was introduced b y a very senior nurse who wandered about the wards saying she had a “tool” that would help prevent hospital acquired infection. The Witch doctor thought perhaps some more sinks for hand washing were about to be delivered to the ward, however it turned out that the “tool” was just a protocol – a sheaf of paper with a multitude of boxes to be ticked. The Witch Doctor asked the nurse concerned why she was calling a protocol a tool.

She said she had been on a management course.

This Tool-Speak is now rife within the NHS. It is spreading like a Blue Bottle Spell. Indeed, it probably is a Blue Bottle Spell cast by some bored witch crashing into management meetings.

I suppose it was just a matter of time before a protocol was designed to help get patients home in order to relieve consultants of patient contact prior to their discharge.

And I suppose it was just a matter of time before they translated this protocol into Tool-Speak.

You don’t get it!!!!

What do you mean “I don’t get it,” My Black Cat?

This is not A Tool to discharge patients home.

This Tool-Speak is to hasten death in a peaceful manner.


If this is the case, My Black Cat, then isn’t it a bit obscene to have A Tool to hasten death.

It all sounds quite violent to me.

Politically incorrect even.

They would be much better calling it A Protocol.

Does this Tool or rather protocol have a name, My Black Cat?

It is called the LCP.

Ah, The Liverpool Care Pathway.


The Liverpool Coma Pathway.

It is something different, is it? Maybe you should try to find out a bit more about The Liverpool Coma Pathway, My Black Cat. It is the sort of thing that, left in the hands of The Human Kind might creep.



(The volcano seems to be having a break at the moment so here are some excellent photographs of Iceland, the land of waterfalls, by photographer Bruce Percy) wordpress stats redapple.jpg POEM OF THE DAY……………………

The Witch Doctor – Link to a random page





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  1. ‘care’ ‘coma’. How these guys love to play with words. It was the same with the Mental Capacity Act, which started off life as the ‘Mental Incapacity Bill’ and got changed. ‘Advocates’ for the mentally incapacitated got changed to ‘consultees’. ‘Best interests’ was the weasel phrase in the whole bill. Beware when people start to play with words. It means they’re up to something.

  2. In my neck of the woods, the great plan is that the elderly should sign up to ADRTs – and so the LCP – and thus their own death warrants. The LCP is a wonderful tool! Not only can it be used to send people home to die (Rapid Discharge) it can also be used to prevent hospitalision! Why waste money on treating the elderly! ELDERLY=TLC=LCP!
    Through research I have discovered that my neck of the woods are not the pioneers of this wonderful idea! It is up and running elsewhere!
    Tool or protocol – I don’t think the name matters – it is spreading like some infectious disease. Humankind are not equiped to notice what is happening – or refuse to see it!

  3. It is interesting that the April 2010 Version 12 of the LCP incorporates a turquoise box of “10 Key messages.” Some of these messages are particularly interesting given the worries about the masking effects of deep sedation:

    4. The LCP neither hastens or postpones death.
    6. The LCP does not recommend the use of continuous deep sedation.
    7. The LCP does not preclude the use of artificial hydration.
    It also says somewhere else that the LCP does not preclude the use of clinically assisted nutrition or antibiotics.

    Since this appears in this years 12th edition of the LCP it begs the question what was in editions 1-11. My feeling is they are now trying to address some of the criticisms raised by people like Peter Millard.

    Incidentally, I came across something called “The Pepsi Cola Aide Memoire” last night.

    Apart from the possibility of creep with the euthanasia enthusiasts always in the background, I have a feeling of unease about the chattering terminology surrounding “the good death”, but I can’t quite put a finger on why I feel this way about it.

  4. I do not have a problem in the LCP per se, in that its aim is to ensure a ‘comfortable’ death. I do have a problem when it is prescribed carte blanche whenever a patient is deemed to be dying. Elderly, pneumonia, no strong family support system – you’re dying!

    I have attempted to find Versions 1-11 without success. I have read Marie Curie’s Updated Statement: 13.10.09 in which it also attempts to address recent criticisms. Quote:

    “Clinical experience has shown that in around 3% of cases, the patients condition can improve and the patient is no longer deemed to be in the dying phase.”

    So were they dying or not when placed on the pathway or just deemed to be dying? I know ‘miracles’ can happen, but is this not just an attempt to deflect criticism? What about those poor sedated souls inappropriately placed on the pathway, who can’t say “Hey! I feel a bit better!”?

    “Treatment with subcut or iv fluids is occasionally indicated when dehydration causes distressing symptoms….” ….

    …. such as agitation and/or delerium?… which would raise the likelyhood that the patient would be sedated to treat these symptoms of dehydration which instead would be deemed as proof of dying. Thirst is a terrible thing and patients recovering from a life threatening illness will sometimes state this was the worst thing they experienced of which they unable to communicate to staff.

    I find it of great concern that not one proponent of the LCP has ever admitted that at times a dx of dying could be wrong. They are blind in their faith in the pathway and will not sit back and reflect. This is when creep sets in and we should all be afraid, very afraid.

    A “Good Death” appeases the conscience of the living and justifies the use of the LCP – whether appropriate or not – for who would not want a patient to have a “Good Death” as opposed to that of pain racked torment?

    Apologies for ranting a bit – but I do have very strong feelings about the inappropriate use of the LCP for I know it exists. As said, when used appropriately it is a wonderful thing.

    • I wonder if the 12th edition has come round to indicating what is nothing other than good nursing, medical and pastoral care etc at the end of life. If so why is the LPC necessary at all? Presumably because dying patients are often not well cared for outside the hospice situation. Why is this? Perhaps the answer can be found in Staffordshire and outlined time and again in Militant Medicial Nurse’s blog. If there are not enough trained nurses in the wards to tend to the needs of the patients who are not dying then there is no point in “rolling out” the magic carpet of the LCP in these wards. That is where creep is very likely to happen. There are other things that worry me about the LCP, but the fact they now say specifically that it is not about deep continuous sedation, then inappropriately use can surely be challenged by waving Edition 12 around.

      I hate the sanitizing jargon that is used around end of life care and agree it is used to appease the conscience and grief of the living. Death is not good but may be some kind of relief for many.

      • I came across “Changing Gear: Guidelines for Managing the Last Days of Life in Adults” today. It can be found here:
        It does not mention clinically assisted nutrition or antibiotics; it does state “Rehydration with fluids is rarely indicated at the end of life and the use of fluids can cause peripheral oedema”

        I also found which question the hydration ‘issue.’

        I find it interesting that No. 4 (Version 12) of the “10 Key messages” states that the LCP neither hasten or postpones death. A 2009 survey by the RCP found patients were typically on the pathway for 33hrs. This cannot be a mean. Thus it would appear that it is an expectation and therefore death is hastened(?).

        I concur with your point raised re lack of trained nurses on wards and thus the impossibility of tending to the needs of patients who are not dying. Perhaps this is why – and I do not lay blame at the door of my fellow nurses working in impossible conditions – some patients begin to fade to the point where they are presumed to be or actually are dying. The LCP (when used inappropriately) a remedy for staffing issues?

        In conclusion I would again like to state that when used appropriately I do think that the LCP is wonderful thing.

      • Sorry Witch Doctor – errors in both email addresses!

        1st should read www. ncpc………
        2nd should read www. chninternational………

  5. Hypercritical,

    I’ve had a look at these two links that seem to reflect the earlier 2006 version of the LCP.

    There are probably many altruisitic reasons for the apparent popularity of the LCP. The cost of care of the terminally ill will be important too. At the moment my thinking is that one of the main reasons for developing this as an explicit “tool” rather than relying on good professional training of medical and nursing staff, is to enable as many patients as possible to die at home cared for by their relatives and a phone-line. It would not surprise me either if “Big Society” volunteers linked to charities are trained in the practical aspects of the LCP and will give support at home substantially decreasing the requirement for trained nurses.

    Pain, confusion and dehydration would be difficult to manage at home but could be eliminated by continuous deep sedation and reassuring relatives that dehydration was a “natural process” associated with life ebbing away. But now in Version 12 this is wobbling because of criticism.

    It will interesting to see if there will be a Version 13 and if so what it comes up with….

  6. I think you are probably correct in thinking that the popularity of the LCP is to enable as many as possible to die at home. Interestingly, the only site I have found where cost savings are alluded to is re Rapid Discharge.

    We have had only one resident returned home to us on the pathway and s/he was deeply sedated and died within eight hours.

    Two residents have been placed on the pathway while at ‘home.’ The first person had had three courses of AB therapy – to no avail and the placement on the LCP was totally appropriate.

    The second was a resident with a terminal cancer.
    S/he reached Step 3 of the pain ladder during a weekend and was placed on the pathway off protocol and therefore was not ‘hooked’ up to a syringe driver. As a result we were in control.
    S/he received only morphine intitially – titrated only once, and hyoscine within the last days of life. This resident lived a further three painfree months (only experiencing pain breakthrough on the one occasion). I fear s/he would not have lived this long on protocol…. and this is what worries me!

  7. Hypercryptical,

    When you say “off protocol” does this mean that the LCP protocol being used would “normally” have required a syringe driver to be used in the given circumstances and would not using one have been classed as one of the “variants” that would be noted on the protocol for audit purposes?

    I’m just curious since I have no hands-on experience with this pathway and am thinking it through.

    • To be honest Witch Doctor – I am still learning too with regards to the LCP. My first experince of it was the resident (X) was discharged to us from hospital. X, when admitted to hospital was still mobile but very confused and prone to falls. The Dx explained this and was a terminal condition. I am not a doc so cannot know if the rapid decline – to warrant the LCP – was to be expected. X returned approx. 8 days later, on the LCP with syringe driver intact.

      Several more of our residents when admitted with pneumonia have been placed on the LCP and of course, not returned to us.

      I presume (Y) whom I described was regarded as ‘off protocol’ as Y was placed on the LCP OOHs. Thus the dx of dying was not that of Y’s own GP nor the decision to place on the LCP. Y’s GP visited on the Monday and informed that the District Nursing Team (who do the deed of ‘wiring’ up) would visit and do the deed – that is, put in place the syringe driver. We and Y’s family did not want this as Y strictly did not meet the requirements to be placed on the LCP – Y still took reluctant sips of fluids, ate a few mouthfuls of food a day and certainly wasn’t semi-conscious! But Y was old! It was agreed that Y should receive morphine by oral syringe and as said, Y lived a further three months.

      I have googled Liverpool Care Pathway Protocol and this would seem to indicate that the use of a syringe driver is the norm. The following: is not as clear, despite its title. There are a few others worthy of reading but the http’s are very lengthy. (I have worn my reading glasses this time – so hopefully the addresses are correct!)

      So I think for audit purposes, perhaps Y would be regarded as a variant?

      • I shouldn’t research after a night shift! Second is as clear and indicates the use of a syringe driver – I have just read it again!

        And now I am not really sure if Y was regarded as ‘off protocol’ re being placed on the LCP OOHs or that a syringe driver was not in place. Perhaps both?

  8. I came across the Ellershaw powerpont demonstration but not the other one.

    I suspect the LCP was introduced with the best will in the world i.e. To ease the process of dying but for some reason it makes my toes curl. One of the reasons I think is to do with the language used in some of the literature … It is full of today’s smart management-speak. I also feel some recommendations could turn out to be quite intrusive both to the dying patient and the family. Ticking boxes is a very unsubtle way of communication. Sometimes, close relatives can communicate to their loved one who is dying without speech at all but this would be difficult to audit of course.

    I have no doubt governments are particularly interested in possible financial savings associated with keeping patients out of hospitals.

  9. Hi WD,

    Do you have a link to the document that says ‘Liverpool Coma Pathway’? I was chatting to a friend of mine about it and she was concerned, cos she works in palliative care.

  10. Julie,

    I have no reference for this term but have heard it used. It is probably a play upon words (or rather the abbreviation) initially introduced by someone disenchanted with the pathway. However, the term does indeed encompass the main criticism of the pathway i.e. that patients will be so irreversibly deeply sedated that clinical improvement cannot be assessed and an original wrong diagnosis of death will not be detected.

    However Version 12 of the LCP seems to address this by stating specifically that “the LCP does not recommend the use of continuous deep sedation.”

    There are a couple of PDF documents that concern me. I’ll probably post more about them soon.

    One makes the statement:

    “The LCP replaces all previous documentation and is the legal document for patient care”

    I simply don’t understand how the LCP can be anything other than guidelines. Perhaps this statement was just made in ignorance.

    Following some links from the origin of the LCP in Liverpool took me to OPCARE 9 an EU funded project and then to a document “The Quality of Death.” I have not read it in full yet but noted that it was produced by the Economist Intelligence Unit who were commissioned by “The Lien Foundation” which is a philanthropic organisation based in Singapore.

    (I found the graphics clever but inappropriate.)

    This suggests there is world-wide interest in the LCP and that economics comes into it – as it surely will.

    I had not found a link with voluntary euthanasia and think those introducing the LCP genuinely want better care for the dying rather than advocating euthanasia, however there is potential for creep particularly outwith hospice care.

    I found possible creep purely by chance yesterday suggesting euthanasia may well be in the thoughts of those on high in the UK but it was not explicit and I’ll probably not post on it.

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