M E N T O R

Why we shouldn’t have got rid of the
Liverpool Care Pathway
Katie Faulkner
You matter because you are you, and you matter until the last moment
of your life. We will do all we can, not only to help you die peacefully,
but also to live until you die - Dame Cicily Saunders
The Liverpool Care Pathway
(LCP) was introduced
in the late 1990’s
at the Royal Liverpool
University Hospital, along with the
Marie Curie Palliative Care Institute,
with the goal of ensuring dignified
and peaceful deaths. Produced
according to best practice and evidence
based research, the intention
was to recreate the care received
by patients in a hospice setting and
apply it to hospital wards as well. It
was not long before the pathway was
attacked for being used to catalyse
deaths, clear beds and save money. A
series of articles were written on experiences
of patients’ families watching
their loved ones dying “an awful
death” on the pathway, with news
headlines depicting the pathway as
“the road to death”, “a one-way ticket”
and, most commonly, “the death
pathway”.
Whilst unethical in itself to display
such a sensitive topic so tastelessly,
the impact of the media meant the
minority of cases where the pathway
was not well carried out over-shadowed
the massive benefits the pathway
had to offer. Enough so that in
2013 the Department of Health and
NHS commissioning board instigated
an independent review of the
LCP establishing a table of 44 recommendations
and, finally, the withdrawal
of the pathway altogether.
For this reason, I will establish two
major principles of medical practice
to explain why it was not only
unnecessary, but unwise to have rid
ourselves of the LCP, whilst also
drawing out what we should learn
from the mistake we have made and
demonstrating why the LCP was an
effective tool in managing dying patients.
The first principle is this: we should
never replace an effective and
well-established practice because
some doctors don’t know how to
use it. The LCP provided beneficial
treatment for patients who were dying,
with numerous stories of good
practice. It is partly because of the
LCP that the care of the dying patient
in Britain was ranked by the
Economist Intelligence Unit as best
in the world in 2010, with quality of
care and public awareness of palliative
medicine recognised as our
main strengths. Likewise, in the independent
review of the LCP, Baroness
Neuberger herself stated,
“there is no doubt that, in the right hands,
the Liverpool Care Pathway supports people
to experience high quality and compassionate
care in the last hours and days of their
life”
The main recommendation given in
her review was simply the use of the
word “pathway” in the name, which
she believed might suggest that patients
are on an unstoppable road
that they cannot step off. These indications,
and many more, demonstrate
that the pathway itself was not
the problem but the application of
the pathway by doctors untrained in
how to use it. It is thought that there
was a great discrepancy in its use;
implemented properly under hospice
circumstances where the staff
are trained to offer the pathway in
its intended holistic nature, versus
the hospital environment where the
pathway was too often regarded as a
tick-box exercise, by staff who were
as impermanent as the patients.
Therefore, should we not have kept
the pathway (in which the problem
did not lie) and improved training
and staff-turnover on wards working
with those managed under the
guidelines of the LCP?
Just as we would not stop giving insulin
as a treatment for diabetics or
anticoagulants for those at risk of
stroke simply because some doctors
do not know how to use them, discarding
the LCP for dying patients
simply because some doctors misused
it denies us of a great tool for
providing very good quality care.
Secondly, it is never acceptable for
the pressure of the public and the
media to dictate how the NHS operates.
In a typical Hippocratic Oath
style, we agree to “provide a good
standard of care, uninfluenced by
political or religious pressure”. We
had been using the pathway for years
and the LCP itself had not really
changed. So, where did this sudden
pressure come from that terrified us
into removing the pathway? Maybe
society’s expectations of practitioners
had increased causing a limited
acceptance of the fact that illness
cannot always be cured which led to
more friction than before between
health professionals and relatives of
dying patients. Maybe increasing
financial and time pressures put on
the NHS meant doctors were less
able to fulfil their roles as previously.
Or maybe the media just love to find
any fault in doctors which they can
use to stir up an emotional response
amongst the public and sell papers.
Whatever the cause may have been
for the pressure put on us to change
our approach towards care for dying
patients, we should never have been bullied
by the medically unqualified to change current
practice. If there is an obvious fault
in the current procedure which needs to
be addressed, it is logical and good to address
it. Yet, withdrawing such a vast set of
guidelines as the LCP without any evidence
to suggest harm caused directly by them is
sadly testifying to the fact that we are unable
to stand strong as a body for what we
have determined is good for public health.
Further to this, by changing current practice
we have actually appeared to agree
with the outrageous claims made in the
newspapers and have confirmed people’s
doubts in our ability to care for their dying
relatives and have given them a reason to
suggest that doctors lack genuine concern
for these vulnerable patients. Instead, we
ought to have spent our time reassuring the
public of the benefits of the LCP and why
it was practised, highlighting positive experiences
such as that of a family spoken of in
the Neuberger Report stating:
“They spoke to us as a family in a sensitive way...
She died with my mother holding her hand, surrounded
by the people she loved in the place where
she wanted to be... I believe we could only do this,
because the LCP provided staff with the guidance
to prepare us for her death and also gave them the
confidence to provide the right care at the right time”.
This brings me on to my final point: the
LCP represented best practice in managing
terminally ill patients in their final moments
and so should not have been removed. Supported
by literature review which showed
that using the LCP promoted better care
for dying patients, it brought the ‘gold
standard’ care found in hospices into a conventional
healthcare setting. Evidence supports
the fact that symptoms could be adequately
managed using the LCP guidelines,
that the LCP provided staff with assistance
in communicating with patients and their
relatives about the patient’s condition and
their eventual death and the pathway recognised
that views of patients and relatives
should be listened to and documented appropriately.
In all ways, the LCP brought
excellence to the care of patients. That is
not to say that the pathway was perfect, but
its problems should have been addressed
individually and corrected; what a waste to
throw it all out and return to the drawing
board.
Dame Cicely Saunders, the founder of the
hospice movement, said,
“You matter because you are you, and you matter
until the last moment of your life. We will do all we
can, not only to help you die peacefully, but also to
live until you die.”
Certain doctors and nurses weren’t doing
all they could do, but the Liverpool Care
Pathway should not be made a scapegoat
for them.
We should never replace an effective and well-established practice
because some doctors don’t know how to use it.
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