Underactive thyroid disease – a modern approach

The Problem

A patient comes to the doctor concerned about longstanding fatigue symptoms. She knows of a family history of underactive thyroid disease and is worried her thyroid is not working properly

Introduction and some basic concepts

[from Basic endocrinology : for students of pharmacy and allied health sciences, edited by Constanti et al (1998; ISBN 9780203301739) ]

The thyroid gland lies in front of the trachea below the larynx. The hypothalamus and pituitary control normal secretion of thyroid hormones. The thyroid hormones in turn control the body’s metabolism. The two active hormones are iodinated derivatives of the amino acid tyrosine. Nearly 90% of the output is thyroxine (T4) containing four iodine atoms while nearly 10% of the output is triiodothyronine (T3) containing three iodine atoms. In health < 1% “reverse” T3 (rT3) is released; this increases in presence of severe illness or starvation. In the bloodstream the thyroid hormones are extensively bound to plasma proteins, principally thyroxine binding globulin (TBG).

Note that in patients on T4 replacement all T3 is produced by peripheral conversion, and so circulating T4 levels may need to be maintained slightly above the “normal” reference range to generate adequate tissue T3 concentrations.

So far so good that is what medical students and other healthcare professionals have been taught to decades. The thyroid stimulating hormone from the pituitary goes up when/if thyroid hormone levels too low, and vice versa.

However this is not the whole story. A more detailed appreciation of the nuances of thyroid hormone metabolism are required to appreciate why so many people with underactive thyroid disease continue to struggle to regain normal health. For example, the story of Coralie Phillips and Donna Roach gives pause for thought about one of the most neglected conditions in general medicine http://www.thyroidbooks.co.uk/ .

Underactive thyroid disease (UAT) is considered simple to diagnose and simple to treat. Luckily this is the case most of the time. Unfortunately when the approach does not seem to be working effectively patients are labelled as difficult or dismissed as mentally ill instead. The medical establishment generally has failed to treat people with UAT scientifically by looking at factors which may conspire to prevent the neat outcome which is expected.

The purpose of this brief essay is to highlight these pitfalls in the hope that fewer people with UAT will suffer in future.

Modern thyroid hormone biochemistry

Role of vitamin D

It seems that adequate levels of vitamin D are necessary to maintain thyroid health.

For example (http://www.endocrine-abstracts.org/ea/0032/ea0032p1008.htm): In this study of 100 patients with autoimmune hypothyroidism compared to 100 subjects as control group, the higher vitamin D deficiency rates besides lower vitamin D levels in the Hashimoto group together with the inverse correlation between vitamin D and anti-TPO suggest that vitamin D deficiency may have a role in the autoimmune process in Hashimoto’s thyroiditis.

Conversely, some evidence emerging that high levels of T3 may suppress vitamin D levels (e.g. http://endo.endojournals.org/content/154/2/609.short) This may be one mechanism for bone losing state of untreated hyperthyroidism (or over-treatment of UAT)

Role of vitamin B12

A new abstract summarises the impact of low vitamin B12 on thyroid disease (and other [geriatric] conditions http://www.bioline.org.br/abstract?rc13008):

Vitamin B12 deficiency is a common condition in the elderly. It is repeatedly overlooked due to multiple clinical manifestations that can affect the blood, neurological, gastrointestinal, and cardiovascular systems, skin and mucous membranes. The various presentations of vitamin B12 deficiency are related to the development of geriatric syndromes like frailty, falls, cognitive impairment, and geriatric nutritional syndromes like protein-energy malnutrition and failure to thrive, in addition to enhancing aging anorexia and cachexia. Therefore, interventions must be developed to include their screening and diagnosis to make early and appropriate treatment to prevent its complications before they become irreversible.

Role of trace minerals

A detailed overview of heavy metals by a nanotechnology team illustrates how important optimising the levels can be for cellular health and ascorbic acid/Krebs cycle [http://www.ijsrp.org/research-paper-0413/ijsrp-p16110.pdf]

 Iron (Fe) Contained in hemoglobin and myoglobin which are required for oxygen transport in the body. Part of the cytochrome p450 family of enzymes. Anemia is the primary consequence of iron deficiency. Excess iron levels can enlarge the liver, may provoke diabetes and cardiac falurer. The genetic disease hemochromatosis results from excess iron absorption. Similar symptoms can be produced through excessive transfusions required for the treatment of other diseases.

 Copper (Cu) Contained in enzymes of the ferroxidase (ceruloplasmin?) system which regulates iron transport and facilitates release from storage. A structural element in the enzymes tyrosinase, cytochrome c oxidase, ascorbic acid oxidase, amine oxidases, and the antioxidant enzyme copper zinc superoxide dismutase. A copper deficiency can result in anemia from reduced ferroxidase function. Excess copper levels cause liver malfunction and are associated with genetic disorder Wilson’s Disease

 Manganese (Mn) Major component of the mitochondrial antioxidant enzyme manganese superoxide dismutase. A manganese deficiency can lead to improper bone formation and reproductive disorders. An excess of manganese can lead to poor iron absorption.

 Iodine (I) Required for production of thyroxine which plays an important role in metabolic rate. Deficient or excessive iodine intake can cause goiter (an enlarged thyroid gland).

 Zinc (Zn) Important for reproductive function due to its use in FSH (follicle stimulating hormone) and LH (leutinizing hormone). Required for DNA binding of zinc finger proteins which regulate a variety of activities. A component of the enzymes alcohol dehydrogenase, lactic dehydrogenase carbonic anhydrase, ribonuclease, DNA Polymerase and the antioxidant copper zinc superoxide dismutase. An excess of zinc may cause anemia or reduced bone formation.

 Selenium (Se) Contained in the antioxidant enzyme glutathione peroxidase and heme oxidase. Deficiency results in oxidative membrane damage with different effects in different species. Human deficiency causes cardiomyopathy (heart damage) and is known as Keshan’s disease.

 Fluorine (Fl) Constituent of bones and teeth. Important for tooth development and prevention of dental caries. Derives from water, tea, and fish.

 Cobolt (Co) Contained in vitamin B12. An excess may cause cardiac failure.

 Molybdenum (Mo) Contained in the enzyme xanthine oxidase. Required for the excretion of nitrogen in uric acid in birds. An excess can cause diarrhea and growth reduction.

 Chromium (Cr) A cofactor in the regulation of sugar levels. Chromium deficiency may cause hyperglycemia (elevated blood sugar) and glucosuria (glucose in the urine).

A recent Turkish paper indicates low zinc levels in saliva (and so plasma) in people with UAT [http://www.turkjem.org/sayilar/79/buyuk/1-4.pdf]. It is not known if this is a cause or effect of UAT but suggests that people with UAT should ensure zinc levels are optimised.

Role of reverse T3?

A recent study highlights the dangers of subclinical hyperthyroidism considering healthy aging associated with decline in T3, unchanged levels of T4, with rise in TSH and rT3 [http://goo.gl/WCUk8]

The process of normal aging affects the hypothalamic-pituitary-thyroid axis in a number of ways, resetting of the set point being the most important of them. Contrary to the earlier belief, longevity has been reported to be associated with high serum TSH. Most recent studies have demonstrated an age dependent decline in serum free T3 levels, whereas FT4 levels remains relatively unchanged and TSH & rT3 levels increase with age. Two recent meta-analyses have shown increased risk of adverse cardiovascular outcomes in patients younger than 65 years of age, but not in those more than 65 year old. There is a good number of evidence documenting increased mortality in elderly individual with sub- clinical hyperthyroidism, which should be kept in mind while treating mildly elevated TSH in these patients. It is also important to remember that thyroid functions in the elderly closely mimics that found in sick euthyroid syndrome.

People with UAT recognise that rT3 levels can rise while they are ill. They make a good argument that rT3 levels ought to be checked in cases of poor response to standard treatment. If rT3 is raised then clearly the the patient is ill and efforts need to be made to restore her/him to biochemical euthyroid state.

Thyroid stimulating hormone response is not predictable

A recent paper by JEM Midgley highlights the problem with depending on TSH to determine whether or not a person with thyroid disease is adequately treated [http://jcp.bmj.com/content/66/4/335.abstract and http://www.hindawi.com/journals/jtr/2012/438037/]

Our data suggest that the states of hypothyroidism, euthyroidism and hyperthyroidism can be regarded as differently regulated entities. The apparent complexity could be replicated by mathematical modelling suggesting a hierarchical type of feedback regulation involving patterns of operative mechanisms unique to each condition. For clinical purposes and assay evaluation, neither the standard model relating logTSH with FT₄, nor an alternative model based on non-competitive inhibition can be reliably represented by a single correlation comparing all samples for both hormones in one all-inclusive group.

Conclusion and approach to the patient

UAT is a common condition though there is still a lot to learn how to accurately diagnose it in all patients. Even if the diagnosis is not elusive the patient’s response to treatment is occasionally not what is expected.

To ensure improved diagnostic accuracy free T3 ought to be checked for all patient suspected of suffering UAT.

Thus it is my practice to check the following in a person who presents with a longstanding history of fatigue with no obvious abnormality on physical examination:

• Full blood count with vitamin B12, folic acid and transferrin saturation index for iron status
• Thyroid function test, including free T3 as well as free T4 and TSH
• C-reactive protein
• Vitamin D level and calcium profile

If patient is proved to have UAT, treatment is started at 25 mcg daily of thyroxine. The patient will be reviewed approximately 2 months later when thyroid function is rechecked with fT3, as well as checking thyroid peroxidase autoantibody (for autoimmune thyroid disease). If there has been a poor response to treatment, copper, zinc and 9am cortisol level should also be checked. rT3 should be checked in all poor responders to treatment too; this is recommended by Thyroid UK.

For details about signs and symptoms of UAT see for example: patient.co.uk
http://www.hormone.org/diseases-and-conditions/thyroid

Some patient resources

UK

Thyroid UK – http://thyroiduk.healthunlocked.com/ http://www.thyroiduk.org.uk/tuk/index.html

International

American Thyroid Association – http://www.thyroid.org/

Association Française des Malades de la Thyroïde – http://www.asso-malades-thyroide.org/

Petition – Better Endocrinological Service and Treatment for Thyroid Patients in United Kingdom

If you agree that more should be done for people with thyroid disease, then please sign the petition here

David Lewis

Hertfordshire

June 2013

Vitamin B12 deficiency – time for a rethink?

Traditional view

NHS Choices offers a traditional view of vitamin B12 metabolism and diagnosis and management of vitamin B12 deficiency anaemia.

An up to date review was published recently link

Vitamin B12 deficiency anaemia or folate deficiency anaemia develops when a lack of vitamin B12 or folate causes the body to produce abnormally large red blood cells that cannot function properly.

The main symptoms of vitamin B12 deficiency or folate deficiency anaemia are:

• tiredness
• lethargy (lack of energy)

View from special interest group(s)

Conversations with members from Pernicious Anaemia Society and B12 deficiency support group indicate there is more to the cobalamin metabolism story than the traditional view describes.

Recent articles and abstracts scattered through the scientific literature point to a more sinister effect on human biology when there is functional deficiency of B12.

• Functional vitamin B12 deficiency may occur at any serum level of vitamin B12 [link]
• Vitamin B12 Deficiency Associated With Concomitant Metformin and Proton Pump Inhibitor Use [doi: 10.2337/dc12-0980Diabetes Care December 2012vol. 35 no. 12 e84]
• Metabolic Globus Pallidus Stroke in Transcobalamin II Deficiency. [JIMD Rep. 2013 Feb 21]
• Adenosylcobalamin essential cofactor for part of the Krebs Cycle, the key energy generator for cellular respiration by mitochondria. Details recently summarised by Hugo Minney at B12D

Adenosylcobalamine, the adenosyl form of Vitamin B12, is needed to keep the TCA cycle running smoothly, and many people with B12 deficiency suffer a “dreadful fatigue”. But it’s a complicated process getting B12 into mitochondria, and an awful lot of things can go wrong.

A key to better understanding is awareness of biochemical reactions in which vitamin B12 is a crucial. These include [link]:

• conversion of odd chain fatty acids (specifically propionate) into succinate
• conversion of homocysteine into methionine via methyl group donation

Medically Unexplained Symptoms – is this a B12 deficiency syndrome?

This week it was proposed that any patient with medically unexplained symptoms should be referred for CBT. It was estimated this may save the NHS £3 million per year. No mention by the authors of the report to explicitly exclude functional deficiency of vitamin B12 [Advances in Psychiatric Treatment (2009)15: 146-151doi:10.1192/apt.bp.107.004606]

Do not forget magnesium deficiency – it is important to ensure magnesium levels are normal in any patient who is taking high dose proton pump inhibitor especially if also prescribed a diuretic agent.

The neuropsychiatric changes caused by functional B12 deficiency may predate the typical changes seen in the blood by months (perhaps years). These are detailed by MacDonald Holmes [JMD Holmes – British Medical Journal, 1956].

McAlpine (1929) said, ” Mental changes occur not uncommonly in pernicious anaemia. They range from states of depression accompanied by loss of mental energy to definite psychoses…” [McAlpine, D. (1929). Lancet, 2. 643]

When there is doubt about the status of vitamin B12 rather than repeat the test in 6 weeks in “borderline cases” as is the present practice, serum methylmalonic acid levels and serum homocysteine levels should be measured.

Measurement of methylmalonic acid, total homocysteine, or both is useful in making the diagnosis of vitamin B12 deficiency in patients who have not received treatment. The levels of both methylmalonic acid and total homocysteine are markedly elevated in the vast majority (>98%) of patients with clinical B12 deficiency including those who have only neurologic manifestations of deficiency (i.e., no anemia). [Stabler, S NEJM 2013]

Implications for general practice

Clearly there is a need to review how we view vitamin B12 metabolism. Recognition in primary care of functional deficiency of vitamin B12 will require medical curricula to pay better attention to this. Haematology does not have a monopoly on clinical features of vitamin B12. There are too few haematologists and neurologists, at least in the UK to provide clinical opinions when vitamin B12 deficiency is suspected. This leaves it to general practice and family doctors to learn more about the protean manifestations of altered vitamin B12 metabolism.

With performance managed healthcare becoming the norm around the world, it may be time to press for explicit scrutiny of vitamin B12 levels in patients with long term conditions including many in the following systems: gastrointestinal, hepatic, psychiatric, neurological, endocrine, renal, and non-malignant anaemias. Only then might we be certain that a scourge of (modern) society will be beaten.

David Lewis

GP UK

Acknowledgement

I would like to thank @b12unme for educating me about this issue. Any errors and omissions are mine.

Netiquette – playing nice on social media

A short note here following the helpful twitter chat today with #hcsmanz [transcript link]

Background

Wikipedia defines netiquette. However, the clearest summary is contained in the following picture:

Better understanding of the conventions for engaging in social media conversations will, hopefully, get more people to stop lurking and join in. Social media conversations are more than tea time conversations. Social media is not only “social” but can be a powerful tool for professional development.

Resources or not reinventing the wheel

Link at Learn the Net – Your online guide

BBC Webwise making the most of being online.

A useful podcast for social media education is The Social Hour [Friday’s 2100 UMT]

Some examples – why social media matters for health and social care

Link to Youth Health 2.0
for articles on social media and mobile technology in public health, e.g.

• Social media and the medical needs of American Indians
• The art of engaging indigenous youth via social media

For (health and social care) professionals @brookmanknight has the last word:

“with medical people I talk collaborative peer support open access learning. Social as a word is not useful to engage or invite.”

Nothing to see here – General Practice serves our children well

February 19, 2013 UK readers awoke to the headline that NHS is failing the children. Why?

• Kids with meningococcal disease are turned away rather than sent to hospital to be cured;
• Children with asthma are not given adequate treatment;
• Too many children are admitted to paediatric wards with minor illnesses
• Doctors prescribe too many drugs which have not been tested on children
• General practitioners do not have proper postgraduate training in child health

At face value such accusations are depressing. The accusations sully the credibility of GPs who are constantly berated for some failing or other every week in the Britain.

Here I hope to show that the accusations are baseless. General practitioners are fantastic physicians who can manage any patient in first contact doctor setting from cradle to grave.

Meningococcal disease in children

This myth perpetuated in the article that children are turned away is based on an article published in 2006 [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)67932-4/abstract, accessed Feb 20, 2013]

Much has changed since that article was published. In any event the study makes no mention of the fate of the fatalities many of whom, one may argue, would have died anyway. Be that as it may, meningococcal disease is less common now Haemophilus influenzae type B (HiB) immunisation is universally available in UK.

Screen clipping taken: 20/02/2013 22:22

Nearly 70% reduction in cases since 2006 is attributable to the immunisation program. Given that millions of GP visits are children, the fact is the chance of any one GP diagnosing a case of meningococcal disease is vanishingly small today. Thus the hazard referred to is scaremongering. The British public deserve better information to make decisions about their kids who develop fevers and blanching rashes. Sadly a reputable charity, The Meningococcal Foundation perpetuates the hazard speculating there are nearly 3,500 cases of meningococcal disease annually in Britain. The figure for 2012 is 443 recorded cases, and many are adults.

Childhood Asthma

Asthma in children is a common condition. General practitioners diagnose the condition regularly. It is a core competency of MRCGP curriculum to diagnose, treat, and manage asthma.

What we cannot do is make parents give the treatment as often as may be needed. We cannot make children and teens take their inhalers regularly. Important risk factor for poor asthma control in youngsters include: parents/carers who smoke, overcrowding, damp, dusty environment. Prematurity is an independent risk factor for bronchial hyperreactivity/asthma. This is important with the upsurge in assisted conception and attendant increase in multiple births which often end in premature delivery of the babies.

Asthma UK does a good job helping people with asthma understand their condition and manage it properly, including an excellent section on inhaler usage.

Screen clipping taken: 20/02/2013 22:36

It is not doctors’ fault that many children have poorly controlled asthma and asthma-like conditions. People with asthma must take more responsibility for the correct management of this long term condition. Wringing of hands that doctors are not treating people with asthma properly perpetuates a State-controlled solution for every ill affecting individuals. This requires better reading comprehension, better education of children to take responsibility for their actions/conditions, and better access to online resources for everyone to improve information flow.

The story about asthma can apply to every long-term condition. There is not space here to enumerate many of the places to look for advice, though NHS Choices and BBC Health deserve wider readership at least in UK.

Minor illness admissions of children

It is a truism that all serious illness begins as minor illness. The trick is to spot which cases may progress. Doctors receive many years of training to learn how to spot the the worrying case. It is an art not a science in this. Suffice to say, like many of my colleagues, I will refer a child to hospital when I fear that worry will stop me sleeping at night about a particular case. This is, I know, not scientific, but when the hairs on the back of my neck stand on end, the child in front of me at that moment will be referred to see a colleague in paediatrics.

If one admits too few patients to hospital, too many unwell children will be taken to Emergency Department out of hours. If one admits too many children, there will be no space for the truly ill child referred by a colleague. All GPs know this. Yes some of us are high referrers while others are not. No-one has discovered what is the ideal referral rate. This is well known to the profession and health economists.

Therefore the accusation in the article is baseless.

Prescribing untested drugs to children

This is a specious argument. With the widespread availability of the British National Formulary for Children, there is a sound basis for prescribing for children in UK (and elsewhere). Yet another baseless accusation threatening to undermine the professionalism of the medical profession in its management of children.

Too few GPs have postgraduate child health training

This is baseless accusation too. General practice curriculum described by RCGP includes core competency in child health. Further, nearly 80% GPs have some postgraduate training in paediatrics before they complete general practice training (at least in UK) [personal communication from Doctors.net website].

Conclusion

The British public has a fantastic primary healthcare service which serves our children well. With a little bit of research it is obvious the article which prompted me to write this is full of inaccuracies and unfounded accusations.

Spread the word

Thank you to Nick Bennett [@peds_id_doc] Assistant Professor in Pediatric Infectious Disease for permitting me to repost here.

The message:  many febrile illnesses in our [Western – developed country] community are due to viruses for which there are generally no effective treatments. If you or your children have a fever it may last up to three weeks and this is not affected by the use of oral antibiotics. So, in almost all cases treat the symptoms – fever control, pain management, light diet with plenty of fluids. [A Cochrane review for basis of this approach in case of respiratory tract infections – http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004417.pub3/full]

culture and sensitivity

I joke that, as a Peds ID doc, it is my duty to say this at least once a day…

Ok, I may not literally be slapping people upside the head, but there are certainly times when I’m doing it in my mind. The situation is common enough – a patient, parent or doctor, faced with symptoms consistent with an infectious disease, considers using antibiotics to treat bacteria. After all, we know that bacteria kill people, right? But in many of these situations the patient really has a viral infection – and viruses aren’t affected by antibiotics. So at the very least we’re wasting money and drugs. Worst case scenario? We’re promoting drug-resistant bacteria, antibiotic allergies and side effects – that in some cases can be life-threatening.

But aren’t there clues to help us make the distinction? Real clinical signs and symptoms? Well, lets review a few.

White pus on…

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Samuel Shem, 34 Years After ‘The House of God’ – Atlantic Mobile

http://goo.gl/TZ3fx A fabulous essay celebrating humanity in healthcare which must be preserved for all our sakes

Shame

A superb essay on addressing “Shame” in order to help people recover from depression and health care professionals develop better emotional resilience.

A Better NHS

Masaccio: The Expulsion of Adam and Eve from Eden 1425

Through the concrete physicality of the two figures and the arid landscape around them, Masaccio makes believable the first dolorous steps of human beings on earth, in the solitude of the shame of sin and the dramatic experience of pain. Quoted from ‘Medicine in Art’ Getty Publications. p.292

One of my patients, June, was standing near the entrance of the surgery when I came back from a home visit. June and I had been through a lot together in the two years since she came to see me with a breast lump, her subsequent mastectomy and chemotherapy, her husband’s dementia and death, and her depression and redundancy, but in recent months she had been steadily recovering and rebuilding her life and her health. The last few times we met she had been really well and we had time to talk…

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Dying with dignity – Liverpool Care Pathway and Palliative Care 2012

With the furore over Liverpool Care Pathway showing little sign of going away it may be a good time to pull together some of the threads. Margaret McCartney has written about the issue in this week’s BMJ (http://goo.gl/VeqY1)

We need to go back to Dame Cicely Saunders who established the groundwork for the specialty of Palliative Care to understand how we arrived at the stage now:

She founded St. Christopher’s Hospice in 1967 as the first research and teaching hospice linked with clinical care, pioneering the field of palliative medicine.

I was a medical student in the 80’s at Monash University, Melbourne. An element of the curriculum included palliative care, especially pain management. We even has a pocketbook to help with prescription of analgesia. Even so, people were still suffering with pain, sometimes horrible pain, right up to death on the wards. The interns and other doctors in training feared giving too much morphine to our patients. The nurses hovered like hawks to ensure we never over-stepped the mark with pain relief. Patient-controlled analgesia was introduced onto surgical and medical wards to improve pain management with variable success (e.g. Macintyre, 2001).

So fast forward to the Liverpool Care Pathway or LCP

The LCP affirms the vision of transferring the model of excellence for care of the dying from hospice care into other healthcare settings.  We have demonstrated a process that inspires, motivates and truly empowers the generic workforce in caring for the patient and their family in the last hours or days of life.”
Deborah Murphy, National Lead Nurse-LCP, Associate Director MCPCIL

A detail of the process is here

So we get to the recent storm.

Daily Mail 13^th Oct 2012

Did NHS kill my mother to free bed? The profoundly disturbing story by son of patient at controversial terminal illness care home
Peter Tulloch believes doctors sought to hasten his mother’s death

He was informed that mother Jean Tulloch had just weeks to live

Without his knowledge, doctors removed her drip but Mr Tulloch believes she was still aware of her surroundings

Daily Mail 14^th Oct 2012

Care? No, this is a pathway to killing people that doctors deem worthless

But, as Margaret McCartney discovered, the Daily Mail was a fan only last year of end of live care that worked:

Daily Mail 30 Aug 2011

I’ll always be grateful to the GP who eased Mum’s pain – even if it hastened her death

This was after an example of poor nursing care at end of life was reported in 2009 in the same paper

Daily Mail 28 Aug 2009

Many NHS nurses are still the finest in the world. But they let my poor father die in agony like a dog

We were treated to a celebration of the care UK citizens receive at the end of life in 2010.

Daily Mail 15 Jul 2010

The country tops the Quality of Death Index, which ranked 40 countries according to the care offered to dying people. In second place was Australia, followed by New Zealand, Ireland, Belgium and Austria.

It cannot be emphasised enough that the model of care exemplified by LCP helps reduce, if not eliminate, the disasters highlighted in the 2009 article. The knowledge, skills and attitudes which the LCP training gives healthcare professionals has virtually eliminated the scenes I witnessed as a medical student in the 80’s.

Now we come to the present again. The Association of Palliative Medicine will review end of life procedures

Daily Mail 24 Oct 2012 and here

the Association of Palliative Medicine has ordered a review of the concerns expressed by countless bereaved relatives, with a promise to explore ways of improving practice.

And the new Health Minister, Jeremy Hunt, has chipped in. (Surely not to gain political points)

Huffington Post UK 3 Nov 2012

NHS Constitution: Families To Get Consultation On ‘Death Pathway’ Decision, Says Jeremy Hunt

But wait! Is there anything actually wrong with the LCP?

Christian Medical Comment 16 Oct 2012

Consensus Statement: Liverpool Care Pathway for the Dying Patient (LCP) 

Published misconceptions and often inaccurate information about the Liverpool Care 
Pathway risk detracting from the substantial benefits it can bring to people who are dying and to their families. In response to this we are publishing this consensus statement to provide clarity about what the Liverpool Care Pathway is – and what it is not. 

Read full statement

The Catholic press also expresses view that nothing is wrong with the system two years ago.

Catholic Herald 23 Apr 2010

A dependable pathway to the life beyond

It is important that death and dying in our community is being debated. With the erosion of spirituality in our lives, our mortality is denied. However, it is so sad that some of the most vulnerable amongst us are being used to sell newspapers and gain political points.
Death and dying is part and parcel of excellent healthcare. The healthcare professionals who work in the NHS (and in private sector) understand this. It is a sign of the times that the authority of healthcare professionals (and priests) at the end of life are being called into question. We are the people who witness more death and dying in civilian populations not at war than any other group in our society. General practitioners with their teams are the midwives to dying process and the grief which follows for those left behind.

To give you an idea of the scope of knowledge and skills involved a selection books has been added.

Helpful Palliative Care resources for healthcare professionals

Paediatrics

Oxford Textbook of Palliative Care for Children

Paediatric Palliative Medicine (Oxford Specialist Handbooks in Paediatrics)

Adults

Oxford Textbook of Palliative Medicine

Oxford Handbook of Palliative Care (Oxford Medical Handbooks)

Palliative Care Nursing, Third Edition: Quality Care to the End of Life

Geriatric Palliative Care

Journals & websites

American Journal of Hospice and Palliative Medicine

Journal of Palliative Care & Medicine

International Association for Hospice & Palliative Care

General and popular books

A selection of books at Goodreads.com

TASME #ukmeded Chat

An excellent opportunity to share ideas with #meded enthusiasts

Med Ed Connect

On Thursday 1st November at 9pm TASME will be hosting #UKmeded chat on twitter.

For those that don’t know, TASME (Trainees in the Association for the Study of Medical Education) is a Special Interest Group of ASME (Association for the Study of Medical Education) that aims to support trainee involvement in teaching. More information can be found on the website here.

The broad topic for discussion will be ‘the role of trainees in medical education’ but as well as trainees, we welcome input from a range of healthcare professionals at all levels. Are you a medical student who struggles to get teaching from trainees that are often too busy? Perhaps you are a trainee who is keen to get involved in med ed but doesn’t know to start? Maybe you’re a consultant that thinks trainees lack the experience required to teach effectively.

Some of the questions we’d like to answer…

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The Things We Carried, Then and Now – NYTimes.com

http://goo.gl/bJa7W Fabulous short essay on what the new doctor of 21st century should carry in their bag