Sunday, 2 December 2012

Investigation into the Liverpool Care Pathway – an update

On Monday 26 November, Care Minister Norman Lamb MP (pictured) convened roundtable talks with parliamentarians, doctors and patients' representatives to discuss the controversial Liverpool Care Pathway (LCP).

During the meeting, which I attended, the Minister announced a far-reaching review to consider the various issues raised, with an independent chair.

The review will consider the findings of three existing reviews being conducted by the Association of Palliative Medicine ('on the implementation of the pathway and the experience of professionals'), Dying Matters ('on the experience of the patient and their loved ones') and the End of Life Care Strategy ('on complaints surrounding the LCP and end of life care in hospitals').

The announcement has understandably received widespread media attention (BBC, Telegraph, Guardian, Mail).

The LCP has been the subject of criticism but has been defended by over twenty leading healthcare organisations and a group of more than 1,000 doctors. One testimony that has drawn a lot of attention is that of Dr Kate Granger, who as a terminally ill cancer patient and geriatric consultant has knowledge of both ends of this issue.

I have previously blogged extensively on the LCP and welcomed the investigation.

Currently about 80,000 patients per year have been supported by the LCP and there is no doubt that it has hugely improved the care of many thousands of patients in the last hours and days of life.

Furthermore the fact that most patients are dying within 33 hours of being placed upon it tells us that they are dying not from dehydration but from their underlying conditions. People usually take 10-20 days to die from dehydration and patients in the last hours or days of life often do not utilise fluids well and have no desire to drink.

However, the LCP has also come under justified criticism for its inappropriate use in some patients who are not imminently dying, its use by junior staff who have not been adequately trained or supervised and the fact that some relatives have not been informed that their loved ones have been placed on it.

Case reports of patients being on the pathway for up to two weeks before dying, or recovering and living for months after being taken off it after protests by relatives have been particularly disturbing and two doctors at the meeting actually called for the withdrawal of the pathway altogether.

If everyone followed the very clear guidelines issued by those overseeing the LCP’s implementation I doubt that we would be having the current discussion.

However it is clear that in some care homes and district hospitals implementation has been sub-optimal.

In order to iron out the abuses several measures need to be implemented:

1.It should be made absolutely clear that no one who is not imminently dying within hours, or at most two or three days, should be placed on the LCP and anyone placed on it who shows improvement should be taken off it. These assessments should be made by senior clinicians.

2.No one should be placed on the LCP without it being discussed with the relative or carer (although the latter do not need to give consent)

3.Every patient placed on the LCP must be regularly monitored and reassessed by a multidisciplinary team.

4.The present documentation is far too complex and needs to be simplified and standardised so that those implementing it can easily follow the guidelines and supervisors can easily tell what is going on with each patient.

5.Training and supervision of those using the pathway needs to be standardised and improved and formal training should be required before any healthcare professional is able to use it.

6.An annual audit needs to be carried out and all suboptimal use identified promptly acted upon.

7.Non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated and every patient treated solely according to their need. In this connection it would be far better to link CQUIN payments to staff training in the use of the pathway rather than numbers of patients placed on the pathway.

8.Communication to relatives both by health professionals and organisations involved in LCP implementation needs to be substantially improved.

9.Those misusing the LCP should be quickly identified and in the case of abuse reported to the appropriate authorities (General Medical Council or Nurses and Midwifery Council).

Every airline accident should make our next air trip safer. In the same way every abuse or misuse of the LCP should mean that the same mistake never occurs again.

We await the result of the investigation with great interest.


  1. Never mind all that - how did it feel to get thrashed by England? The great All Blacks brought to their knees, eh? And you thought your team were invincible....

    1. Not at all. It was a fantastic performance by England and a well-deserved win.


    2. Of course it was. Good of you to admit it!

      Very proud of our lads.

      And you haven't answered my question, have you? So, again, how did it feel to get thrashed by a team you so despise?

      Admit it, Peter - you have well-balanced chips on both shoulders about us Brits. I guess it's an inferiority complex really :)

    3. England thoroughly deserved the win and they won fair and square and I feel just fine actually. After all we can hardly complain that we haven't had our fair share of victories over the years. I'm looking forward to the next game.


    4. Ah, yes. You HAD to bring in all that stuff about your fair share of victories - obviously. Just in case we didn't already know, eh?

      As I said, massive inferiority complex. Do all Kiwis have a chip on their shoulders, or is it just you?

      >> I'm looking forward to the next game.

      Me too, matey.

    5. In fact if England beat us next time they will equal the NZ cricket team's record against Australia of 8 wins and 27 losses :-)

    6. the liverpool care pathway is cold blooded murder.

  2. Point is peter, its done without patients express consent...and soooo many victims relatives are having b-all to do with it, its pointless anyway. They've admitted they've rolled it out without proper training...and that's Corporate Manslaughter....why bother discussing the matter with a DoH that is so deceitful, its deliberately going to delay holding the inquiry until the NHS bill and the Assisted Dying bill are safely through parliament? And as they've already admitted its flawed, why havent they suspended it? That's gross negligence manslaughter ain't the 'controlling mind' itself....

    1. The DoH have not admitted that the LCP is intrinsically flawed, only that there have been abuses and misapplications.

      My impression at the meeting was that they intend to move on the enquiry very quickly.

    2. to peter saunders, stop defending the liverpool lazarus pathway because your involved in the use of it, tell mp fiona bruce how good it is the patients should be treated not executed.

  3. i think the liverpool care pathway is the most evil act the nhs has ever been involved in and the staffordshire hospital like the pathway there should be murder inquires and it should be abolished instantly to save lives.


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