Category Archives: Medical reporting

A sad day for palliative care

Three weeks ago I wrote about my dismay at the Daily Mail’s attack on the Liverpool Care Pathway. This week Baroness Neuberger’s team has published its report: “More Care, Less Pathway.” Amongst its recommendations is this:

The name ‘Liverpool Care Pathway’ should be abandoned, and within the area of end of life care, the term
‘pathway’ should be avoided. An ‘end of life care plan’ should be sufficient for both professionals and lay
people.
Unsurprisingly the Mail is gloating over its victory:
  • Ministers order Liverpool Care Pathway to be ditched within a year,
  • Review by Baroness Neuberger reveals how end-of-life treatment was used as an excuse for appalling levels of care
  • Families were not told their loved ones were on the ‘pathway’ to death

The Mail has been leading a campaign against it…

I stand by every word I wrote three weeks ago. I am quite disappointed by how much the report has pandered to the Mail. If you read the comments sections of my last post, you will see many of the commentators are strongly opposed to the LCP. Whilst I think many of the comments are misguided, and just plain wrong I have not moderated any of them. (Unlike the Mail website which always blocks all of my comments posted as ‘alienfromzog’). I want to take this opportunity to respond to the comments, to the report and to the Mail. My main frustration is that when you read what people think caring for the dying should involve, it’s often words like “Caring,” “TLC” or “Individual” are used. Similarly many relatives say they want good communication. What is so frustrating is that this is precisely what the LCP is. What it’s for. If you don’t believe me , read this: Marie Curie Example LCP documentation.
It took years to recover from the damage done to the vaccine program by the Mail’s irresponsible reporting – and we’re still not there yet. This is why the Mail is so malevolent. And yes, I do blame the Mail in part for the children who have died of measles. Years of hardwork, research, evidence and education – all undone by Melanie Phillips and her malicious publication. And who suffers? The most vulnerable in society. There have been various articles and blogs written to defend the LCP. In all of them that I’ve read, they begin with an acknowledgement that the LCP used inappropriately has led to many of the problems reported in the press. I have not done that and this is deliberate. I am not pretending that bad practice does not occur. It does – in all areas of healthcare and all healthcare systems. I will always condemn bad practice but the idea that not using the LCP pathway properly means there’s a problem with the LCP is ridiculous. Moreover, by beginning with such acknowledgements I believe that all these articles and also the Neurberger report has conceded too much ground – allowing the LCP critics to claim victory.
Perfectly preventable problems of communication between clinicians, relatives and carers
appear to account for a substantial part of the recent controversy and unhappiness
surrounding the LCP.
I care about quality of care. Abolishing the LCP will make the Daily Mail happy. It will make the government look like they’re doing something and will almost certainly lead to less-good care. Almost without exception, the critics have said “Care of the dying should be….” and what follows that, as I said above, is in the LCP. So, in order to improve care we plan to abolish a tool that works when used properly rather than addressing the issues that lead to it not being used properly. This is insane. But then, that’s what government by tabloid press always is. My great fear is that scrapping the LCP will mean a return to ad-hoc, ‘hit and miss’ palliative care. This is a major backward step.
I do want to address a couple of specific points as well; firstly the LCP is not euthanasia by the back door. Secondly the payments for use of the LCP to hospitals have been presented as money for killing off patients and this is a gross misrepresentation.
I am against euthanasia. I think giving doctors the power the kill is a grave error – even when people are suffering horribly. Good palliative care is the very opposite of euthanasia. My professional experience – and this is especially true in children – is that we over-treat to the nth degree. We are not good in the profession in acknowledging that we cannot cure and fix everything. Most of us in medicine are ‘fixers’ by nature. A lot of what we do in medicine is nasty and invasive. I have no problem with doing nasty and invasive things to people who will benefit from them. I have major issues with doing nasty and invasive things to people when it will not help. This is about not having another round of chemotherapy when we know it won’t help. This is about not force-feeding people with artificial nutrition as their body shuts down. This is about not doing endless – and increasingly difficult  – blood tests just so we can chart the dying process. Integrating care pathways for dying patients mean we provide comfort and care for people in their last hours and days. This is vital.
The way the NHS funding works is quite complicated. Since the early 1990’s there has been a so-called purchaser-provider split and hospitals then get paid for providing specific treatments. One of the parts of this is so-called ‘quality-care indicators’  (or whatever they’re called this week). Essentially a portion of the money paid by primary care trusts / GP consortia is dependent on meeting the quality indicators. One such indicator was the use of the LCP in dying patients – x% was the threshold for payment. This actually makes a lot of sense; Let us assume that the LCP provides an excellent framework for caring for dying patients. Secondly, all patients who die in hospital are categorised as ‘expected’ or ‘unexpected.’ Death is often not a surprise – i.e. medical staff know that a patient is in the last phase of illness. The internal audit process simply reviewed what percentage of the ‘expected’ deaths were on the LCP when they died – i.e. had the medical team stopped doing invasive procedures on someone or were they still trying to cure? Nothing is absolute and some patients will die unexpectedly. Some people will have a theoretically reversible condition and it is right to keep on treating and yet we still fail – but the evidence is clear, in the majority of cases, we know someone is dying and the focus of care should change. A simple audit of whether the LCP is used of not is a good marker of this. The use of money to drive things is an inevitable consequence of how the modern NHS is structured – a perhaps cynical view that NHS trusts will only do things for financial incentives. On a more practical level, the trusts used this money to pay for specialist palliative care teams to support the use of the LCP and help the other clinical teams use it effectively. The abolition of such payments is a sensible political move but will probably also result in trusts not focusing on palliative care.
Speaking as the son of someone who died in an excellent hospice; speaking as a doctor who has worked on the wards where integrated care plans for dying patients have been used – and as someone familiar with LCP specifically I say this:

This is a very sad day for the healthcare in the UK. There is not a problem with the LCP – there is only a problem with poor practice – rarely. The number of patients who have received excellent care far outweighs the few who haven’t. Not that those don’t matter, they really do but I am sure that the bad practice was worse before we had integrated care for dying patients and will probably be worse again. What’s most annoying is when you read the comments sections or listen to radio phone-ins people talk about what they want end-of-life care to look like and it is precisely what is in the LCP. It is worrying to me that the Daily Mail wrote a couple of sensational and misleading articles and forced this change of policy. Deeply worrying. I know that a small group of people in the late 90s worked very hard to put together the research and develop the LCP. I suspect they are very demoralised. I know a lot of people work in palliative medicine and I expect they are depressed and despondent. All because a lying, evil rag – not even fit to be fish ‘n’ chip wrapping – calls itself a newspaper and constant prints streams of lies and sensation. A sad day.

Dr alienfromzog BSc(Hons) MBChB MRCS(Ed) DCH

Liverpool Care Pathway – The Daily Mail vs Care for the Dying

An inevitable philosophical question:

I’ve been occasionally contributing to Angrymob for a few years now. Kevin (aka Uponnothing) very kindly gave me a login. I write because I care about the truth. I write because I believe that the lies and agenda of the Mail are pervasive and damaging. I write because I hope to share my thoughts with enough people to help change the story – to help people realise what the media in general and the Mail in particular are doing. To provide the facts – as best I can – so that people who know the Mail is lying have the ammunition to respond.

I have no idea really if I’m achieving anything.

But the question that I’ve pondered for sometime now – especially when I read stories like this one – is what is going on within the Mail? I wonder if they believe what they write? I wonder if they just want an agenda to push? And I wonder what level of research they do before holding a particular position?

Either way, what they publish is demonstrably false and often deeply poisonous. This is why I have written about vaccines so much. The recent events in Wales with measles have shown the real-world effects of the Mail’s agenda. And this is moreover true is so many areas – immigration, race relations, the Welfare State, the NHS, our attitudes to poverty…etc. etc.

So, whilst I continue to ponder that question, which I admit does intrigue me greatly, I will try to continue to respond when I have the time. For the most part I write about healthcare issues as this is what I know about.

On the subject of poverty I invite you to read this from my personal blog. (I make no apology for the theology).

 

The Liverpool Care Pathway

I think I should begin with a confession; I am not a big fan of the LCP. I will explain that comment in a moment but first I need to alter it slightly. My feelings have changed and I have become very keen to defend it because the attack by the Mail seeks to (well maybe not, see above, will- ) damage the way we care for the dying in this country. If you want to read about the pathway itself and to understand what it is and how it works, here is a good place to start.

Simply put, the LCP was designed to consolidate best practise in the care of dying patients. In the UK we have a hospice movement to be proud of. Most people, however don’t die in hospices – most people die in hospitals. Historically (by which I mean the last 30 years) and culturally, hospitals are not conditioned to best care in the process of dying. Hospitals are places for curing. Modern medicine particularly is built on the notion of curing everything. Trust me, doctors know this to be a lie. Most of us have had enough humbling experiences with meeting death to know that we can’t cure everything and that the old saw about medicine being the art of delaying the inevitable is not without its truth. However, and this is a vital and massive ‘however’ – we are in the business of healthcare. Providing curative treatment when possible and appropriate and dignity, compassion and comfort when not.

Recognising that a patient is dying is notoriously difficult but experienced nursing and medical staff will tell you that we often know that it’s time to stop. I graduated in a time when these kind of approaches were widely accepted and beginning to be more formalised. It is about the fact that most people die relatively slowly – by which I mean hours to days  and not the seconds to minutes we see in TV and movies. Given that putting everyone in a hospice is not practicable, I think most of us will agree that providing the best kind of end-of-life care in hospital is a priority.

The principals are this: When a patient is near to death; stop unnecessary and invasive interventions (like blood tests) and treat symptoms effectively. This usually means three things; analgesia, treating anxiety and treating secretions.

The Liverpool Care Pathway codifies these in a way designed to ensure that best possible care is provided. Feeding may be stopped as in the last few days as artificial feeding does more harm than good.

So why do I not like the LCP? Well, this is not really my area of medicine and as I’ve moved into my specialty of paediatric surgery, I haven’t done any adult work for over three years now. But I was a junior doctor on the wards – and anyone who has done that job will have dozens of stories of how the LCP is a really effective way of CARING for dying patients. My objection is the same as that of a professor of palliative care I know, the LCP is a little cumbersome and involves too much paperwork and it got a lot of national attention and funding  – potentially at the expense of other areas. But is does work. Really well.

The LCP is very very good at what it does. The LCP – or something like it – is exactly what I would want for me, for anyone I love – or for any human being near to death.

 

The Daily Mail’s latest Witchhunt.

Back in November, I picked up on Melanie Phillips evil comment piece on the LCP and its effects. I do not use the word ‘evil’ lightly but something so completely dishonest that increases distress and anxiety for people who are watching loved-ones die I think is evil. If someone wants to provide me a better word, please do. Again I don’t know if Phillips is being dishonest of just not bothering to research properly – but I suspect dishonesty as she has never effectively engaged with the debate or criticism – where it has been repeatedly demonstrated where she is wrong.

And so we come to this week’s piece. The British Medical Association has been discussing the LCP and the public’s perceptions leading to this Daily Mail headline:

‘Don’t call it the Liverpool Care Pathway': Doctors admit it sounds like a one-way ticket to the grave

  • Leading doctors have admitted that there are problems with the controversial end of life care regime
  • Involves withholding food and water from the dying patient and is meant to help them die with dignity
  • Doctors admitted some patients have been left on it for weeks without having their case reviewed
As always, the culpability lies with the medical profession and not with the Daily Mail for printing misleading articles… The implications that doctors are killing patients or that they don’t care or that somehow this is a NHS initiative to save money are ———– well, I don’t know, I’ve run out of adjectives… (insulting, misleading, offensive, damaging, dangerous, horrific, indefensible, typical for the Mail, wrong, cynical, plain dishonest) – take your pick!
Well, actually I think all of those and then some more:  The implications that doctors are killing patients or that they don’t care or that somehow this is a NHS initiative to save money are insultmisleadinglyoffensivelydamaginglydangeroushorrificlyindefensiblelytypical-for-the-Mail-wronglycynicallyplain-dishonestetc!
As always the comments section provides a worrying perspective, but this is my favourite:
comment
No my dear-UKIP Supporter the reason they don’t have this ‘uncomfortable controversy’ in the States, is I suspect, because they are blessed enough not to have the Daily Mail.
AFZ

Freedom for what? To kill young women?

As regular readers of this blog know, the Daily Mail believe that the vital importance of a free press is an excuse for anything they want to do. The confluence of reporting and commentary is so insidious and malevolent. Many newspapers are guilty but the Mail is the biggest culprit.

For me, one of the best examples of this is in the reporting of vaccine stories. I have written about this before. I wonder if I should apologise for covering old ground, but then as long as the Mail puts real lives are risk by cynically exploiting people’s fears in order to push an agenda and sell newspapers, I think I will feel compelled to respond.

So the current Mail  campaign is against the HPV vaccine: Girl, 13, Left in ‘Waking Coma’ and Sleeps For 23 Hours a Day After Severe Reaction to Cervical Cancer Jabs. Now, you don’t have to be a doctor to begin to doubt the veracity of the headline, simply reading the article itself is a good start;

“But just weeks after she received the third dose of Cervarix in May this year she began to feel exhausted.”

Let’s just cover some facts:

  1. Cevical cancer is caused by a virus (Human Papilloma Virus).
  2. The current vaccine protects against 70% of the strains that cause cancer
  3. By preventing the virus infection, the vaccine prevents the cancer
  4. If you look at the data (also in the article) the vaccine is very safe.

The subject of this article has been diagnosed with chronic fatigue syndrome. This remains a controversial issue for lots of reasons, not least because despite a lot of research, a cause has not been clearly identified. Therefore to ascribe her symptoms to the vaccine that was given weeks before is a very speculative statement at best.

Lets have a look at the little information panel they’ve included:

Now I assume that they’ve got this data from the MRHA (The medicines and healthcare products regulations agency). On their website I couldn’t find the up to date figures because they don’t publish them routinely but they are available on request. However the initial figures from the first two years are here. The importance of this is how closely vaccine reactions are tracked and recorded. So lets look at the side-effects; 4445 out of over four million vaccines is around one in a thousand reported side-effects. Of those the vast majority were local reactions and rashes. Now I don’t want to underestimate the significance of a sore arm, but I think cancer can be quite nasty too. Allergic reactions are important, because a severe reaction can be very dangerous, but the figures for anaphylaxis are extremely low. The final comment about Guillan-Barre syndrome is also very disingenuous. GBS is a nasty condition but it occurs sporadically and rarely in the population all the time. The important point is that people notice when they occur after a vaccine. If the two really were linked then the rate in the vaccinated population would be higher than the background rate. It is not.

Please remember people, coincidence is not the same thing as causation. It seems that if something occurs around the time of the vaccination, then the vaccine must be to blame.

I firmly believe that the press has an important role to play in keeping the powerful accountable. However, making stuff up and stoking up fear is something very different. I wouldn’t mind but the HPV vaccine will save many young women from a horrible and early death. If the vaccine really is dangerous then we shouldn’t use it. But it’s not. The ever-increasing evidence is that the vaccine is very safe.

I wonder, if in 15 years time someone did a study which showed that cervical cancer was massively more common amongst the daughters of Daily Mail readers, would they publish an apology? No, I thought not.

Here’s a headline for you:

Reading the Daily Mail can cause cancer in your children!

 

AFZ

What’s your poison?

The wonderful people behind the NHS Behind the headlines section have released their first in-depth report on how media coverage impacts public perception of a particular medical issue – in this case, alcohol. The report – What’s Your Poison: A sober analysis of alcohol and health in the media – examines the media’s relationship with research on alcohol, the science behind it, and what all this means for us when we consider raising a glass. In particular it discusses the media’s need to treat most research in absolute isolation from each other; something which leads to the constant contradictions surrounding alcohol reporting.

For example, one day drinking red wine is lethal, the next day it is the secret to long life or a potential cure for cancer and so on. Furthermore, few of theses stories actually point out the well-known health problems with alcohol (i.e. liver problems etc) and instead spend their time questioning whether various drinks are the cause of or cure for cancer which is kind of missing the point about the dangers that are well-established.

Anyway, it is an interesting report and one that has come about thanks to the NHS Behind the Headlines team realising just how poor the standard of medial reporting is in the UK.

Go here and read the whole document.

‘Scare over miscarriage scans unjustified’

From the NHS Behind the headlines blog:

Several news sources have today reported that errors during early-pregnancy ultrasounds are leading to unnecessary abortions. The Daily Mail said that hundreds of babies a year may die due to ‘blunders’ in testing and the Metro said that unreliable tests caused a baby to die every day…

Despite what headlines have suggested, early pregnancy ultrasounds are invaluable and highly accurate diagnostic tools, and even using current guidelines, the vast majority of cases would be accurately diagnosed…

It should be noted that while the researchers did suggest there may be around 400 cases of misdiagnosis each year, there is no indication that the majority of them would be terminated, as newspapers have reported…

The news is based on four studies examining the use of ultrasound scanning to monitor early-stage pregnancies…

Press coverage of these studies tended to be quite alarming, with suggestions that 400 babies a year die or are terminated due to errors in testing. For example, the Metro ran front-page coverage saying that ‘a baby per day dies due to test error’, while the Daily Mail said that fears were ‘hundreds of healthy babies are being aborted every year simply because of scan blunders’.

However, this figure appears to be based on one research paper that estimated around 400 UK pregnancies may be misclassified as miscarriages, which does not necessarilly mean they are terminated.

At a press conference attended by reporters from a number of national newspapers, some of the study authors stated that there was no reliable source of evidence to confirm how often misclassified pregnancies would be terminated…

Also, many press stories were accompanied with pictures of late-stage ultrasound scans, showing clearly visible foetuses. This would suggest that doctors are performing terminations close to the natural end of pregnancy, when in fact these studies were concerned with diagnosis within the early stages of pregnancy, when an embryo might typically be around 5-6mm in length.

Read the full examination of the research here.

Do computer games leave children with ‘dementia’?

Daily Mail headline: ‘Computer games leave children with ‘dementia’ warns top neurologist’. The first two paragraphs of the article:

Children’s brains could be left damaged and they could suffer temporary ‘dementia’ by playing computer games, a leading scientist has warned.

Eminent neurologist Baroness Susan Greenfield said yesterday that spending time online gaming and browsing internet sites such as Facebook could pose problems for millions of youngsters.

Three paragraphs from further on in the same article:

However, she did not reveal any research that had made a connection between screen technologies and brain degeneration.

Professor Mark Griffiths, a psychologist and Directory of Nottingham Trent University’s International Gaming Research Unit, said he knew of no scientific evidence that such a link existed.

He said: ‘If anything the fact computer games are arousing can aid education by keeping children engaged.’

So, basically she is speculating that constantly being at a computer screen could damage your brain (for example, if you spend too much time on the Mail website) but she fails to provide any evidence to support her hypothesis. The Daily Mail chooses to ignore that and prefers to instead publish a headline that clearly implies the claim is based on evidence – i.e. if they accurately reported what the neurologist had said the headline would read: ‘Computer games could leave children with ‘dementia’ warns top neurologist’ rather than: ‘Computer games leave children with ‘dementia’ warns top neurologist’.

Paul Dacre doesn’t seem to realise that there is a lot more to bad journalism than just phone hacking and that tougher regulation isn’t just a result of that one crime, but rather the fact that the vast majority of newspapers publish bullshit every single day.

The Unacceptable state of medical reporting

A recent study found that when compression-only CPR was conducted by bystanders with the assistance of a dispatcher the survival rate of victims suffering from cardiac arrest improved. The NHS Behind the headlines team point out that the researchers ‘do not advocate from their findings that people should make a deliberate decision to avoid mouth-to-mouth resuscitation without guidance from the emergency services’. Furthermore:

Importantly, all the incidents included in this study were of out-of-hospital cardiac arrest due to heart-related problems; the researchers say that other studies have found that standard CPR is better for cardiac arrest with non-cardiac causes (e.g. drowning, trauma and asphyxia, which would be the case in most arrests in babies and children). [emphasis is mine]

The NHS try to make clear that this is important, ‘well-conducted research’ but that the ‘findings only apply to this population in these specific circumstances, and do not apply to the general public in all circumstances’. They even point out that ‘many emergency medical dispatchers in the UK make recommendations to bystanders of an adult cardiac arrest that are broadly consistent with these findings anyway’.

So, how did our responsible media report these findings?

First up the BBC goes with: ‘Study backs chest compressions in resuscitation‘. They start with:

Concentrating on chest compressions rather than mouth-to-mouth when giving emergency resuscitation can produce better results, says research published in The Lancet.

Although they give plenty of information they fail to really gets to grips with the specificity of what the researchers found and the reader is probably left with the impression that avoiding mouth-to-mouth when performing CPR is always likely to produce ‘better results’. Therefore the article is, to a certain extent, misleading.

Next up the Telegraph chooses to go with: ‘Skip the ‘kiss’ when giving the kiss of life doctors recommend‘. The article starts with:

Skip the ‘kiss’ when giving the kiss of life, doctors advise, as study reveals performing only chest compressions is more effective at saving lives.

Again, the article fails to mention the specificity of the results and is accompanied by a photo of two female lifeguards, one performing CPR on the other on a wet beach. Clearly the photo is illustrating the resuscitation of someone who has drowned, a situation in which traditional CPR (with the ‘kiss’) is better according to the NHS (see above). The article is broadly the same as the BBC in that it is misleading because it generalises very specific findings – in particular the Telegraph’s assertion that ‘doctors advise’ people ‘skip the “kiss” when giving the kiss of life’ is a complete invention given the very limited set of recommendations given in respect to a very specific set of circumstances.

Finally, the Daily Mail went with: ‘Kiss of death: Does mouth to mouth put lives at risk?‘. As usual the Daily Mail feels the need to sensationalise the headline to a frankly ludicrous degree and the start of the article continues the trend:

It may be called the kiss of life, but mouth-to-mouth resuscitation could actually be anything but.

According to experts, the treatment can in fact hinder heart attack patients’ chances of survival.

As with the other two articles the Mail fails to gets to grips with the specificity of the researcher’s findings, preferring to concentrate on implying that this ‘kiss of death’ technique is being taught to a legion of potential killers:

Doctors are so concerned they are calling for the technique to be left out of CPR guidelines for the condition.

This technique is widely taught in schools, offices and to those who help at big sporting events.

Clearly the Daily Mail is attempting to make people panic, implying that if they have a cardiac arrest in school, at work or at a sporting event someone may attempt to kiss them to death. Not surprisingly the Daily Mail coverage of this story has by far the most panic-inducing tone and imagery, a tone which as usual is contradicted later in the article by some details that make the headline look distinctly wrong. These two sentences towards the end of the article for example:

However, mouth-to-mouth shouldn’t be removed from the first-aid repertoire altogether, as it can still be effective if a patient stops breathing, but their heart is still beating.

This could include those who are choking, are near to drowning, victims of carbon-monoxide poisoning or those who have taken a drug overdose.

These two lines seem to contradict the initial claims the article makes that it is the ‘kiss of death’ and acknowledge that mouth-to-mouth can still be ‘effective’ – although they fail to mention that traditional CPR with mouth-to-mouth is actually more effective in these cases. I think the primary reason for this is that mentioning this fact would catch them in a nightmarish loop – they would have to write a second headline declaring ‘can CPR without the kiss of life kill?’ simply because CPR with mouth-to-mouth is more effective in certain circumstances.

This quandary just demonstrates the utterly irresponsible, simplistic and fear-inducing headline that the Mail has gone with. The truth is never simple, but the Daily Mail insists that its articles must be, hence the huge discord between the original findings of the researchers and the black-and-white reporting of the Daily Mail. The result – headline declaring that mouth-to-mouth is a potential killer, end of the article declaring that it is still effective and important in some cases – can only lead to confusion. People walk away from the article unsure about whether mouth-to-mouth is or is not safe to use – and cynical about the researchers involved (just read some of the comments posted) because they blame then for the contradictions rather than the reporter.

There is no excuse for this kind of journalism, given that the NHS Behind the headlines team can explain it so effectively and rationally.