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.