Tuesday 16 October 2012

The Liverpool Care Pathway – consensus statement from 22 organisations

Twenty two leading healthcare organisations last month published a statement about the Liverpool Care Pathway to counter adverse publicity in the mainstream press.

I have written extensively on this controversial end of life treatment protocol before and won’t rerun the arguments here except to say that this new statement is well overdue and hopefully will go some way to quelling concerns.

The full statement, which has had surprisingly little publicity, reads as follows:

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.

The hospice movement in the UK is famous around the world for looking after dying people with dignity and skill. Since the late 1990s, the Liverpool Care Pathway has been helping to spread elements of the hospice model of care into other healthcare settings, such as hospitals, care homes and people’s own homes.

The Liverpool Care Pathway:

•Requires staff ensure all decisions to either continue or to stop a treatment are taken in the best interest of each patient. It is not always easy to tell whether someone is very close to death – a decision to consider using the Liverpool Care Pathway should always be made by the most senior doctor available, with help from all the other staff involved in a person’s care. It should be countersigned as soon as possible by the doctor responsible for the person’s care.

•Emphasises that people should be involved in decisions about their care if possible and that carers and families should always be included in the decision-making process. Of those who responded as part of the evaluation, 94% said that they had been involved (National Care of the Dying Audit – Hospitals, MCPCIL/RCP, 2011).

•Relies on staff being trained to have a thorough understanding of how to care for people who are in their last days or hours of life.

•Is continually evaluated in all the places where it is in use.

The Liverpool Care Pathway does not:

•Replace clinical judgement and is not a treatment, but a framework for good practice.

•Hasten or delay death, but ensures that the right type of care is available for people in the last days or hours of life when all of the possible reversible causes for their condition have been considered.

•Preclude the use of clinically assisted nutrition or hydration - it prompts clinicians to consider whether it is needed and is in the person’s best interest. GMC guidance (2010) provides specific information regarding this issue.

In response to a question asked in the House of Lords on 20th June 2012 the Parliamentary Under Secretary of State for Health, Earl Howe, said (see full parliamentary debate here):

“The Liverpool Care Pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good.”

The Liverpool Care Pathway has been suggested as a model of good practice in the last hours and days of life by successive national policy frameworks (DH, 2003 and 2006), the national End of Life Care Strategy (DH, 2008), Quality Markers and Measures for End of Life Care (DH, 2009), General Medical Council guidance (2010) and the NICE quality standard for end of life care for adults (2011).

We support the appropriate use of the Liverpool Care Pathway and make clear that it is not in any way about ending life, but rather about supporting the delivery of excellent end of life care.

Age UK
Alzheimer’s Society
Association for Palliative Medicine of Great Britain and Ireland
Association of Directors of Adult Social Services
British Geriatrics Society
British Heart Foundation
English Community Care Association
Help the Hospices
Lindsey Lodge Hospice
Macmillan Cancer Support
Marie Curie Cancer Care
Motor Neurone Disease Association
Multiple Sclerosis Society
National Care Forum
National Council for Palliative Care
National End of Life Care Programme
National Nurse Consultant Group (Palliative Care)
Nuffield Trust
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians
Sue Ryder


  1. Elizabeth RGN MA Bioethics26 November 2012 at 17:24

    Peter - did you watch the Newsnight debate on LCP. Mary Warnock of 'it is the duty of everyone diagnosed with dementia to die..as they are a burden to the NHS' and Terry Pratchett who campaigns for the legalisation of assisted dying.The difference between them is Mary Warnock does not mind involuntary euthanasia - no consent but interestingly Terry Pratchett said he was very troubled by what he heard - no emphasis on the 'informed consent of the patient concerned'. Because that is what is patently missing from the LCP - the informed consent of the patient which is a breach of GMC regulations. Apart from abortions, this is the only procedure that is allowed to go ahead without expressed and informed consent! Each consultant on the panel and your article states that the patient is placed on the LCP if the doctor decides it is in the 'patient's best interests' - regardless it appears of what the patient or his family feel is in his best interest.

    As you know an advanced directive can only consent to the 'withdrawal of medical treatment' (and thanks to Evan and John Harris food and fluids were redesignated from normal nursing care to a 'medical procedure' to facilitate the killing of Anthony Bland) - and advanced directive cannot insist of treatment being continued and prevent the withdrawal of medical treatment against the patient's expressed consent.

    Our local hospital is the hospital that received the greatest payout. There is also a payout for organ harvesting - not an incentive according to the Organ Donation Taskforce but the 'removal of financial obstructions for Trusts to engage in the identification of potential donors and calling the transplant team'. In addition the organ harvesting criteria have been conveniently changed to allow older donors and the use of 'less than optiminal organs' -works nicely doesn't it.

    I am very surprised to hear you supporting the LCP unequivocably - not requiring a re-assessment. You state that the decision to place a patient on the LCP is taken by 'the most senior doctor on duty'. Well recent research shows due to lack of senior staff and properly trained junior doctors, patient are much more likely to die overnight and over the weekend - why therefore do you think this is safe?

    Also the RCP has just released a report led by Mike Richard highlighting the practice of doctors and Trusts withholding treatment or surgery from cancer patients for whom the doctor decides is 'futile' and not in the 'patient's best interest' with the result that these patients are not receiving the correct care and are dying before they should. Ring a bell?

    Finally I would address my fellow medical and nursing colleagues and ask 'why are you so pathetic and unprofessional that you are not prepared to scrutinise this practice and why is your only response to the appalling stories (which I have heard personally not via the DT or the DM) I have heard to aggressively defend yourselves.' It clearly demonstrates you do not really have any concern for your patients but only for you fragile egos!

    1. UK medical student27 February 2013 at 05:29

      In your first paragraph you talk about consent being necessary for being placed on the LCP. Good practice says 'yes' but legally, the answer is 'no'. A key part of the LCP is stepping down invasive procedures, so doctors do not need to get consent for that. Think about it: you have no legal right to a new treatment from your doctor/ nor a continuation of an old treatment, even if you think you need it. E.g. Patient: 'I want a cast.' Doctor: 'But your leg isn't broken.' Patient:'But I demand you put a cast on! I have the right to any treatment that I want.' Doctor:'Oh okay.' What a disaster. Stepping down treatment is always down to the clinical judgent of the clinicians and in a dying patient it is better for the experienced dr to make the call than families who may never want to let go, whatever the cost to patient's integrity.


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