The Liverpool Care Pathway (LCP)

This week I plan write about the LCP, something which has featured in the news in recent weeks. Its aim is to provide a sustained quality of care amongst all patients in their last hours/days of life to ensure a peaceful and comfortable death.

It is described as the “best practice model for care of the dying” and can be used to support patients in care homes and their own homes as well as hospitals.

So, why was it introduced? In the 1990s end-of-life care was somewhat “patchy” for example some hospitals provided excellent care whilst others did not meet the same standards. Areas of particular concern were that firstly patients were often subject to invasive testing/treatment that offered no chance of preventing death and secondly that the patient was caused unnecessary pain and suffering by needlessly prolonging life.

Information regarding the pathway on the Marie Curie Palliative Care Institute website is split up into three main areas…

1.      Medication/treatment review.

Any medication that is not helpful at this time may be stopped. In addition it may not be appropriate to continue some tests at this time, for example blood tests, blood pressure and temperature monitoring.

Finally patient comfort must be considered, monitoring bed position to prevent bed sores, the potential use of a special mattress and regular mouth care.

2.      The diminished need for food and drink.

Such a need could be a physical sign that their condition is not going to improve. The patient may neither want nor need food/drink and decisions about the use of artificial fluids should be made in the patient’s best interests.

3.      Religious/spiritual needs.

Discussion with the relative and where possible the patient to ensure that the desires at the time of or after death are met.

The pathway has featured in the news throughout November, it has faced criticism and scrutiny from many newspapers. For some its use has become controversial, with relatives reportedly claiming it has been used without consent and others have reported it being used inappropriately to meet targets.

However the LCP has been standard practice for a number of years now, so whilst there have been recent allegations of individual failings within the procedure (mainly due to lack of communication between those involved), the model of care itself appears to be both appropriate and humane.

As a result of the recent accusations Care and Support Minister Norman Lamb said he would appoint an independent chair to report on the issue. He said,

"It is clear that everyone wants their loved ones' final hours of life to be as pain free and dignified as possible, and the Liverpool Care Pathway is an important part of achieving this aim. However, as we have seen, there have been too many cases where patients were put on the pathway without a proper explanation or their families being involved. This is simply unacceptable.”

"Today I have committed to appoint an independent chair to review how end-of-life care is working and oversee the reviews into the LCP. This will report back to me in the new year." (Source: BBC News)

Randomised controlled trial showing spinal cord regeneration (in dogs)

A research team in Cambridge recently undertook the first double blind trial (neither the researchers or the pet owners knew which pets were receiving the real treatment) to test a transplant technique involving olfactory ensheathing cells in "real-life" spinal injuries suffered by dogs. Real life in the sense that the dogs were injured spontaneously and accidentally rather than in the controlled environment of a laboratory. The treatment was also given sometime after the injury occurred.

The transplant consisted of olfactory ensheathing cells* being removed from the lining of the nose. These were then grown and expanded for several weeks in the laboratory.

*The only part of the body where nerve fibres continue to grow in adults is the olfactory (smell) system. Olfactory ensheathing cells (OEC) which are found in the back of the nasal cavity surround the receptor neurones that enable us to smell and convey these signals to the brain. These nerve cells need constant replacement which is promoted by the OEC.

It has been thought for some time that OEC may be useful in spinal chord repair and this recent study supports this.

The trial provides "proof of concept", of the 34 dogs involved 23 had OEC transplanted into their injury site - the remainder were injected with a neutral fluid (a placebo). The results were positive, many of the dogs which received transplant cells showed considerable improvement and were able to walk on a treadmill with the support of a harness. As expected no improvement was seen in the control group.

The transplanted cells regenerated nerve fibres across the damaged region of the spinal cord. As a consequence the dogs were able to regain the use of their back legs and more importantly co-ordinate movement with their front limbs.

However these new nerve connections did not occur over the long distances that would be required to connect the brain to the spinal cord, something which would be crucial for human spinal injury patients who had lost sexual function and bowel/bladder control. Given that in a survey of spinal injury patients these two factors were rated higher in importance than improved mobility.

So how significant is this research and what are its possible clinical implications/benefits for the future? Well, Prof. Geoffrey Raisman who discovered olfactory ensheathing cells in 1985 said "this is not a cure for spinal cord injury in humans - that could still be a long way off. But this is the most encouraging advance for some years and is a significant step on the road towards it." Furthermore despite the recovery seen amongst the dogs in the trial, in humans "the much harder range of higher functions lost in spinal cord injury - hand function, bladder function, temperature regulation, for example - are yet more complicated and still a long way away."

(Source: BBC Health News - also click here to see a video of the transformation from immobility to unassisted mobility in one of the dogs)

"Vegetative state"

There is a Panorama special on BBC 1 tonight giving an insight into the lives of patients in a vegetative state and the consequent effect on their families.

However there is not complete agreement on the topic of vegetative patients, what does it mean to be "vegetative"?

The group of patients involved in the programme have all suffered from brain injuries, usually through trauma such as a car accident or perhaps another condition such as a stroke or viral infection.

The patients are different to "locked-in patients" whom I have previously written about, those who are paralysed however their brain function is normal and they can often communicate through eye movements. Vegetative patients are different as the brain damage suffered is so severe it leaves them with nothing but core reflexes, ie no brain function. They may be able to move their limbs or eyes but it cannot be due to command or controlled.

The Royal Hospital of Unpredictability (RHN) in London involved in the programme invented a vegetative assessment technique, SMART, which explores all five senses to detect any potential form of cognitive awareness or an ability to communicate.

In addition a fascinating brain scanning technique has been developed by Prof. Adrian Owen and his team which uses functional Magnetic Resonance Imaging (fMRI) to detect hidden awareness amongst patients who may be deemed vegetative by observational assessments.

The technique has recently been used to show hidden awareness in a Canadian patient, Scott Routley, who was believed to have been in a vegetative state for over ten years! Assessments since the car accident twelve years ago (the cause of the brain damage) have shown no signs of awareness or communication until now.

The patterns shown by the scans of brain activity show he is clearing choosing to answer questions. During the research healthy volunteers were asked simple questions and asked to think of the answer for a period of time, before saying it, whilst their brains were scanned. The same questions were then asked to brain damaged, vegetative patients and the images recorded were compared to those of the healthy volunteers and in Scott's case they showed cognitive function and understanding.

Observational assessments of Scott's behaviour since the brain scan continue to suggest he is in a vegetative state. In the future will scans such as the one using fMRI be used in addition to observational assessments to decide if someone is in a vegetative state?

Finally Prof. Adrian Owen said "asking a patient something important to them has been our aim for many years. In future we could ask what we could do improve their quality of life. It could be simple things like the entertainment we provide or the times of day they are washed and fed." (Source:BBC)

Movember

Firstly I should apologise for my lack of posts recently, the reason for this is that I have been on holiday for the past two weeks! Lucky me! However I am now back at school and into the full swing of things and plan to write a bit about Movember this week, an amusing take on November with a very good cause behind it!

The idea began in Australia in 2003 with Adam Garone and has since evolved into a worldwide fund raising campaign to raise awareness for men's health, particularly prostate cancer. The "Mo" in Movember is Australian slang for moustache and the idea behind the campaign is to begin the month of November clean shaven and grow a stylish moustache to show your support and gain sponsorship for doing so.

Prostate cancer is the most common cancer amongst men and around 36,000 men are diagnosed each year in the UK. The prostate itself is a small gland (about the size of a walnut) located between the penis and the bladder.*

As a consequence symptoms of prostate cancer are usually urinary related and only noticeable when the cancerous tumour has grown large enough to put pressure on the urethra. For example needing to urinate more frequently, difficulty in starting to urinate and weak flow.*

However such symptoms are not a definite indicator of prostate cancer as the prostate gland can get bigger as men get older and press on the urethra causing similar symptoms. This is known as benign prostate disease.*

The diagnosis of prostate cancer is not straight forward but often involves a screening test followed by a biopsy. The levels of prostate-specific antigen (PSA) (a protein produced by the prostate) in the blood can be measured however levels can also increase with age. A patient could also undergo a digital rectal examination (DRE), this is an examination of the rectum which is close to the prostate gland to feel for a hard bumpy area. Finally a biopsy of tissue is taken from the prostate and is studied in the lab for cancerous cells.* (*Source: NHS Choices)

The slogan of the charity is "changing the face of men's health one moustache at a time" - quite literally!

This video on 'Ted Talks' about Movember is REALLY worth watching, its informative but will definitely make you laugh and is given by Adam Garone himself.

The campaign has three main aims: to improve awareness and educate the general public, provide survivor support programmes and fund prostate cancer research. Since it's founding it has become the largest contributor to the Prostate Cancer Foundation and raised over $126 million last year.