healthmedicinet

• Senior doctors described the scheme as ‘very worrying’
• They fear it could repeat the failures of the Liverpool Care Pathway
• Critics say paramedics could prevent patients getting life-saving treatment

By
Jonathan Petre and Stephen Adams

PUBLISHED:

18:58 EST, 27 July 2013

|

UPDATED:

20:15 EST, 27 July 2013

Ambulance crews are being told not to take patients to hospital if they have been put on controversial ‘death lists’ drawn up by GPs.

Serious concerns were raised last year after it was revealed that thousands had been placed on ‘end-of-life’ care registers so they could be helped to die rather than receive hospital treatment.

Now The Mail on Sunday has learned that ambulance crews responding to 999 calls are being alerted if a patient is on a list, and can refuse to take them to hospital if they have previously expressed a wish to die at home.

Controversial: Ambulance crews are being told not to take patients to hospital if they have been put on controversial ‘death lists’ drawn up by GPs. This is a file picture

Senior doctors described the scheme as ‘very worrying’ and fear it could repeat the failures of the Liverpool Care Pathway (LCP), a set of clinical guidelines for the dying that was scrapped earlier this month following a damning independent review.

Critics said that under the new scheme, patients might not realise the consequences of choosing to die at home.

They said it could mean paramedics deciding to leave them there rather than taking them in for what could be life-saving treatment.

They added the system would cause unnecessary worry to relatives who found they were unable to rely on emergency hospital care when they called for it.

Under the scheme, when someone on an ‘end-of-life’ care register calls 999, their names will be flagged up on an electronic database, revealing whether they have expressed a wish to die in their own bed.

The ambulance crew will then decide whether they should take them to AE or call in other health professionals to treat them at home.

Concerns: Ambulance crews responding to 999 calls are being alerted if a patient is on a list, and can refuse to take them to hospital if they have previously expressed a wish to die at home

NHS bosses admitted paramedic crews were not experts and said they should consult the patient’s doctors  if they had any doubts – though they conceded that could be difficult to do.

But London-based hospital consultant Dr Philip Howard said: ‘Patients may have said they want to die at home but at three o’clock in the morning, when they suddenly become breathless, the family panic and they want to go to hospital.

‘It must be very distressing if you have got somebody who is dying with a lot of pain and you can’t access the doctors.’

Neurologist Professor Patrick Pullicino said: ‘I don’t think ambulance crews should be involved in these decisions ethically. If you call an ambulance you expect to be taken to hospital.’

The new row comes just weeks after Sir
David Nicholson, the chief executive of NHS England, said that future
NHS planning would focus largely on care in the community for the
elderly and people with long-term conditions, and ‘providing services
wrapped around their needs that prevents admission to hospital’.

Health bosses have tried for years to reduce the number of people dying in hospital because surveys have shown that many more people would like their lives to end in their own beds than actually do.

But critics fear there is a financial motive behind the plans – and official estimates seen by The Mail on Sunday suggest the NHS could save more than £50?million a year if it slashed the numbers dying in hospital.

Over the past two years GPs have been asked to compile lists of one in every 100 of patients who they believe will die within 12 months.

Doctors are under no legal obligation to tell these patients they are even on these lists, leading to fears of secret ‘quotas’.

But doctors are asking many of these patients whether they want to agree to care plans, including where they want to die, and ‘living wills’ in which they can instruct medics to withdraw life-saving treatment if they become incapacitated in hospital.

Only when these care plans are in place are patients – three-quarters  of whom say they want to die at home – flagged up to ambulance crews.

Ministers want all patients close to death to have these care plans in place, with IT systems that flag them up to local ambulance services, hospitals and GP surgeries.

Crews are alerted en route if a patient has a care plan in place so they can assess them on arrival. If the patient’s problem is not linked to their terminal illness, they may be taken to hospital.

But if it is appears to be part of the illness detailed in their care plan – such as the patient experiencing much more pain than normal – then the crew would have to decide whether or not to take them into hospital.

Way forward: Sir David Nicholson, the chief executive of NHS England, said recently that future NHS planning would focus largely on care in the community for the elderly and people with long-term conditions

Senior London Ambulance Service paramedic David Whitmore, who helped set up the capital’s Coordinate My Care (CMC) system, said: ‘At the end of the day if the patient’s wish is to die at home, we have to do our level best to honour that wish.’

But he said paramedics were not typically trained to spot if someone was entering the final hours of life – meaning the decision about whether or not a patient would benefit from AE treatment could be difficult.

There was a pressing need for ambulance
crews to be better trained at identifying the signs of impending death,
he said, and patients and carers had to understand that death at home
could be very difficult to deal with.

‘When you ask people where they would
like to die most people will say “at home”. Often the reality can be
very distressing. Understandably they forget to call the palliative care
teams and call 999.

The CMC helps us to get that back on
track and reduce unnecessary admissions to hospital.’ The register is
held at the service control room and information is relayed to crews
when answering an emergency call.

Mr Whitmore said the intention is to
have up to 57,000 patients on the system in the next few years. But
Elspeth Chowdharay-Best, honorary secretary of the Alert pressure group,
said: ‘We are told repeatedly that most people want to die at home.

Guide: This is an NHS end-of-life care programme booklet

‘They don’t actually mean that they want to die quite soon, but that is what might happen if an ambulance refuses to take them to hospital.

‘Are these people warned when this choice is recorded that they may become very ill when they are dying, so that their elderly husband or wife may have to provide 24-hour nursing for an indefinite period?’

Mr Whitmore said health teams had to be ‘bolstered’ to ensure families were not left to cope alone as  a loved one died.

A guide produced by the Association of Ambulances Chief Executives says that the service is making the changes because  it is fully committed to developing ‘high quality end-of-life care’.

The document, Route To Success, also envisages a benefit to the NHS of ‘decreased costs, due to a decrease in unnecessary hospital admissions’.

Economic models published by the NHS in May suggest that encouraging more people to die at home with care plans could save up to £275?million over five years. Each hospital death costs £1,480 but those at home are cheaper, it noted. The policy is part of the Department of Health’s end-of-life care strategy.

Dr Julia Riley, from London’s Royal Marsden Hospital, who has been instrumental in setting up the system, stressed that doctors needed patients’ consent to set up care plans about how they wanted to be treated in their final days.

She believed doctors were wrong to fear that patients who chose to die at home would be denied potentially life-saving hospital treatment. 

‘There will always be one-offs, but we have now created 6,633 urgent-care records and the feedback from GPs, patients and relatives has been overwhelmingly positive,’ she said. She added that ambulance crews  can ‘override’ care plans and take patients into hospital if they thought that was in their best interests.

But she was worried that the  system could be rolled out too fast. Fewer than 7,000 people have agreed to these care plans so far in London, which is by far the biggest system of its type.

If all of England is covered by them, the number will eventually top 400,000.

The Liverpool Care Pathway, which started as a way of helping cancer patients have a comfortable death in a handful of hospices, became discredited in part because it was badly put into practice once it was rolled out to many hospitals.

Dr Riley said she believed this would not happen with the CMC  system because it enabled doctors to get weekly feedback on how it was working. But Dr Gillian Craig, a retired consultant geriatrician from Northampton, said that the philosophy underpinning end-of-life care registers was ‘deeply flawed’.

‘It sounds an unwise and unsatisfactory arrangement and I would question the accuracy of a GP’s prediction that any individual patient  is going to die within 12 months because predictions such as these can be often way out – years out.’

Another problem with the policy, she added, was that it would be difficult to police unless a post-mortem was carried out on every patient  who died in their own homes to see  if ‘there was something that could have been treated and should have been treated’.

‘That is extremely unlikely to happen,’ Dr Craig said.

One accident and emergency department is refusing to take 999 cases at night because of  a shortage of doctors – and another unit could follow suit.

Tonight is the last night that Cheltenham General Hospital will take in blue-light ambulance cases.

In the future, patients  will be taken to Gloucestershire Royal Hospital eight miles  away, which is run by the same hospital trust.

The closure, from 8pm to 8am, will affect almost 6,000 patients a year. A similar shutdown is planned from next month at King George Hospital at Ilford in Essex.

Cheltenham Lib Dem MP Martin Horwood said he feared the night change could be the first step towards the AE’s overall closure.

‘The trust has repeatedly maintained it has no plans to close AE at Cheltenham.

‘But  if blue-light admissions are diverted first at night and then during the day, and then more and more GP referrals are taken to Gloucester, Cheltenham’s AE will in effect have become a minor injuries unit serving  a town of 120,000,’ he said.

‘I think the pressure is now on Health Secretary Jeremy Hunt to tackle the AE problem because it is getting politically pretty toxic.’

Mr Horwood’s concern follows  a report by the Commons  Health Select Committee on Wednesday. It warned that just one in six casualty units had enough consultants working during the busiest hours of the day – between  8am and midnight. Most  were ‘relying too heavily’  on junior doctors.

Central Middlesex Hospital closed its AE unit between 7pm and 8am last November due to a shortage of doctors in what was meant to be a ‘temporary’ move’. It has not reopened overnight and the department is now mooted for closure.

At troubled Stafford Hospital, the AE was also ‘temporarily’ closed overnight last December, and in March plans were announced to strip the hospital of its department altogether.

Dr Clifford Mann, an AE consultant and president of the College of Emergency Medicine, said doctors should be paid twice their normal rate to entice them to work unsociable shifts.

Dr Tom Llewellyn, an emergency consultant at the Gloucestershire hospitals, said: ‘Our priority is to ensure that the sickest patients are seen by very skilled specialist staff.

‘The proposals for change  to night-time services at Cheltenham were developed  for service quality and safety related reasons, which includes the availability of experienced emergency medicine doctors.’

Gloucestershire Hospitals NHS Trust, which runs both hospitals, said there were ‘no plans for further changes’  to Cheltenham’s AE unit.

Meanwhile in Essex, plans that would see blue-light ambulances diverted  from King George Hospital AE at night from next month are being considered by  the Barking, Havering  and Redbridge University Hospitals NHS Trust.

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The comments below have been moderated in advance.

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Paramedics aren’t stupid, they can tell if someone is approaching the end of their life, if they have expressed a wish to die at home, and a family member/carer has panicked and phoned for an ambulance, then shouldn’t we be doing everything we can to support their wish?! Unless the patient states otherwise, or it is a treatable condition like broken bones, or infection.

–

Kate
,

England,
28/7/2013 03:33

Report abuse

Is this some kind of legal euthanasia!

–

Sparky11
,

Beverley, East Yorkshire,
28/7/2013 03:31

Report abuse

This is disgraceful!!!!

–

WannabeJourno
,

liverpool,
28/7/2013 03:21

Report abuse

If people are put on this system they should have their GP’s home phone number then the paramedics could call and discuss the situation. That should help the paramedics and avoid mistakes.

–

despairingeric
,

Crawley Uk,
28/7/2013 03:18

Report abuse

I cannot understand why you have written a negative story about respecting a person’s wishes to die at home.

–

batsupporter
,

Bristol,
28/7/2013 03:14

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We get less less for more more money

–

joncris
,

Bridport, United Kingdom,
28/7/2013 03:11

Report abuse

I believe the main reason for this is our paying £55 million per day into the EU – we should be spending that money both on the NHS and on tax cuts across the board to stimulate our economy (which would raise more money for the NHS due to the increased trade).

–

UKIP Supporter
,

Bromley,
28/7/2013 02:36

Report abuse

All this beating about the bush regarding how government can let people die, by this method or the Liverpool Pathway, where if they had the guts to allow voluntary euthanasia, it would be kinder and more merciful to give people the same treatment any animal would get. SO WHY DON’T THEY???.

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Alan
,

Huddersfield,
28/7/2013 02:31

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It appears to me you don’t need a wish care plan to die at home, the call centres are doing it for all of us.

–

Sensible1
,

Oxford, United Kingdom,
28/7/2013 02:17

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No, no, no, no, no, This is no way to treat people. HOW DARE THEY think this is acceptable.

–

Londonlondon
,

London, United Kingdom,
28/7/2013 02:16

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