By continuing to use the site you agree to our Privacy & Cookies policy

Less than 50% of terminally ill patients put on Liverpool Care Pathway

Less than half of all terminally ill patients are placed on the nationally recommended Liverpool Care Pathway for the Dying Patient (LCP), new research has revealed.

In many parts of England, medical staff have limited training or support to use the care pathway, according to a study published in the BMJ Supportive & Palliative Care journal.

The pathway was developed by the Marie Curie Hospice Liverpool and the Royal Liverpool University Hospitals in 2003 to help healthcare staff caring for patients dying of cancer in hospitals.

It has since been expanded to include all dying patients and has been implemented across the world in primary and secondary care settings.

The pathway provides a framework for structuring and coordinating multidisciplinary care for the last 72 hours of life and facilitates audit by standardising the monitoring of patient needs, symptoms and care.

However, until recently there had been little reliable information on how frequently the LCP was used across the country.

Researchers at Durham University’s Wolfson Research Institute for Health and Wellbeing reviewed the evidence of the eligibility, uptake and non-uptake of the LCP in various settings.

Collectively, 18,052 patients were placed on the LCP, in a variety of inpatient and primary care settings, and cancer and non-cancer diagnoses, the study’s authors found.

In the UK, the LCP is cited in National Institute of Health and Care Excellence guidance as an example of good practice.

Nevertheless, the LCP has been the source of media controversy, with stories in the national press last year describing it as the “equivalent of euthanasia for the elderly”.

There were also claims that many doctors considered it “worthless”, leading to hundreds of complaints to the Press Complaints Commission.

A poll published by BMJ and Channel 4’s Dispatches in March this year found that 89% of palliative care experts backed the pathway and would choose it for themselves.

However, three-quarters (74%) of palliative medicine consultants said the negative media coverage had led to less use of the pathway.

Are you able to Speak Out Safely? Sign our petition to put pressure on your trust to support an open and transparent NHS.

Readers' comments (27)

  • Yep, the Liverpool Pathway is now a no-no where I work, following the furore created by the media in recent times. Numerous times - when relatives have been given the news that their loved-ones condition is now entering into the palliative stage - have I heard them say: "I don't want them on that pathway."

    I fear we'll end up back where we were before the pathway was introduced which can't be a good thing for palliative care.

    Unsuitable or offensive?

  • Too much time filling in forms whilst the patient died five minutes previously alone and without the carer holding their hand who had felt safe to nip out to get another form but had to print off fresh ones whilst the nurse sits in the office completing the LCP audit and updating care plans ready for the forthcoming inspection.
    Bring back real nursing, not one man semi-automatic care teams who look to academics and lawyers for guidance and not wise counsel based upon compassion and experience.

    Unsuitable or offensive?

  • michael stone

    'The pathway provides a framework for structuring and coordinating multidisciplinary care for the last 72 hours of life and facilitates audit by standardising the monitoring of patient needs, symptoms and care.'

    How can you be 'on' a framework - and isn't individualised care, something that will potentially be lost if people think of this framework as 'a pathway' ?

    All dying patients should be treated as individuals, and as part of social/family groups where that is the case, appropriate palliation should be offered (which is where 'evidence-based' medicine comes in: working out what works, and therefore what it makes sense to offer) and those clinicians caring for the dying should KEEP THINKING.

    The LCP, when viewed as a combination of a description of 'tested methods of care' AND AS A PROMPT (the prompt being to change mindsets from 'cure' to 'helping to die') makes great sense - it becomes wrong, however, if it is thought of 'as how patients will die, and something we therfore fit patients into'.

    I think - not quite sure - that much the same was being said by:

    Anonymous | 4-Jun-2013 3:27 pm



    Unsuitable or offensive?

  • There is so much to say but is it safe given the all round controversy? Try approaching the subject from a personal perspective and imagine dying against what you see routinely applied in these circumstances. Would you want morphine confusion and a hyoscine dry mouth with carers not giving you anything in case you aspirate? Think of a child taking an uncertain step..what do they need?..a hand.

    Unsuitable or offensive?

  • Why will people not accept when their loved ones are dying? I've recently started working in a hospice and have been very impressed by the standard of care and the individualisation of people's needs as they enter the final stages of their lives. The LCP is useful as a check list to ensure that everything is in place and prescribed to make things comfortable, so that the nurses and the family can concentrate on making those last precious days or hours as gentle as possible.

    Unsuitable or offensive?

  • Anonymous | 4-Jun-2013 8:10 pm

    "Why will people not accept when their loved ones are dying?"

    hopefully you will learn about the psychology of bereavement whilst you are there which will help answer your question. the writings of Elizabeth Kübler-Ross are also an excellent source of information.

    Unsuitable or offensive?

  • Anonymous | 4-Jun-2013 8:10 pm

    "Why will people not accept when their loved ones are dying?"

    You have a lot to learn and one can only hope that you learn quickly.

    Unsuitable or offensive?

  • Anonymous | 4-Jun-2013 3:27 pm

    "Bring back real nursing, not one man semi-automatic care teams who look to academics and lawyers for guidance and not wise counsel based upon compassion and experience."

    Exactly.

    Unsuitable or offensive?

  • tinkerbell

    Anonymous | 4-Jun-2013 5:05 pmThink of a child taking an uncertain step..what do they need?..a hand'

    What a lovely way to put it.

    I once attended a personal course with Elisabeth Kubler Ross, a lovely lady, so very down to earth, so encouraging. We shared a fag together in the grounds of the castle where we were staying but she didn't want anyone to know she had one in case it reflected badly on her in the press. Now she's no longer with us i guess
    she doesn't care.

    Unsuitable or offensive?

  • tinkerbell | 4-Jun-2013 10:39 pm

    you are very privileged.

    she wrote her last book with a co-author when she was dying herself. she had so much insight into the feelings and needs of dying patients having written numerous books and interviewed hundreds of dying patients. I once heard on the radio a doctor recommend that every member of the caring professions should read her book 'On Death and Dying'. It has been on my list ever since and for such a long time but somehow other things always seem to need attention and take priority but I am sure it is well worth the read.

    Unsuitable or offensive?

  • tinkerbell

    yes do read it, it's not very long and not wordy. One evening a few of us on the 'workshop' (urgh) as they called it, were sitting around chatting,all nationalities but some americans, there was some very 'way out there' treatments they were discussing, more new age treatments etc., there was a bit of a lull in the conversation when i said very seriously 'i read toe nail clippings' and one of the group said enthusiastically 'really?',
    'No' I replied,' i'm only joking'
    And the ex nun, beautiful woman, who was a co- facilitator but english said to me with a big smile on her face
    'you wicked child'.

    Unsuitable or offensive?

  • michael stone

    Good care, especially of the dying, involves, as a nurse recently wrote to me (if the link below works, you can find this and other e-mails):

    ‘Particularly when people are near the end of their lives and decisions are made for them, not with them, or no one has bothered to ask them about their feelings or choices before they may get to a point where it is difficult to communicate what they want/like /prefer

    In my experience people very much appreciated being treated as an individual with a life history as well as being a partner in their care and not being done to in a task orientated way’

    As I said earlier, provided patients ARE ‘being treated as an individual’ (and not being 'done to' as opposed to making their own decisions) then I’ve got no problem with the LCP as a framework of clinically-tested OPTIONS: although, more than one person commented to the Neuberger Review that the name isn’t as good as it might be (although it isn’t obvious what you change it to).

    As Keith Price (GP ret, York) The Times page 35 Friday November 9 2012 Letters Section, wrote:

    ‘As an ex-professional I recognise the important impact of the Liverpool Care Pathway in improving the care of the dying patient. However, its application must take note of the fully informed wishes of close relatives, many of whom have been nursing their seriously ill relatives for some time at home in difficult circumstances.

    I implore hospital and hospice staff and primary care practitioners to involve patients and relatives throughout each step in the pathway, thus avoiding the inevitable deep disappointment and anger which may ensue from its unilateral application. As with every branch of medical practice good communication is essential.’

    Dr Price was clearly still furious that his wife had been sedated without her requesting that sedation, after her death: and so would I have been.

    The link for the full e-mail and others:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?forumID=45&obj=viewThread&threadID=694


    Unsuitable or offensive?

  • michael stone | 5-Jun-2013 1:54 pm

    frankly i resent your constant lecturing on how experienced nurses should be doing their job. Frankly I have never seen anything but the best nursing care given to dying patients and support to their families in the realms of the possible with the available resources and even by other nurses, who were total strangers to us and not my own colleagues, in a different hospital to the one I worked in, to my own Mum.

    I have over thirty years experience working mainly in general medicine, medical and surgical rehabilitation, mental health and care of the elderly. we often stayed over time and sometimes late into the night to accompany a dying patient and support their bereft relatives and to relieve our colleagues on duty. This occasional involved cancelling our own social engagements.

    my colleagues and I, on the acute and chronic medical ward, where I worked for 20 years agreed that such a hospital setting was not the best place to die because of all of our other heavy duties and emergencies we had to deal with, but death was not always foreseen giving us a chance to plan for it and fit it in around all of our other tasks, and did not always come at a time for everybody else's convenience, but we always gave our very best to provide each patient with individualised and holistic care according to their present needs which could change very rapidly from one moment to the next and sometimes with only one registered nurse on duty. Every moment we were not engaged in other duties the dying patient, as well as their entourage, would always be our first priority and we did not need any clinical pathways telling us how to do it.

    Unsuitable or offensive?

  • from Anonymous | 5-Jun-2013 2:15 pm

    michael stone | 5-Jun-2013 1:54 pm

    and by the way I do not spend my time answering most of your repetitive posts but just wished to forward my view that not all care of the dying patient is bad and most experienced professionals actually do care and know how to look after the patients they are presented with which includes those as they reach the end of their lives.

    Unsuitable or offensive?

  • michael stone

    Anonymous | 5-Jun-2013 2:15 pm

    Re:

    'I have never seen anything but the best nursing care given to dying patients'

    well, that retired GP had seen poor nursing care - it isn't 'good care' to sedate a terminal patient into 'insensibility' without asking the patient. It isn't good care to put people on the LCP (whatever that means) without consulting patients or relatives; it isn't, in my view, 'good behaviour' to put clinical DNACPR Decisions in place, without telling patients/relatives unless there are very good reasons indeed.

    And I do NOT doubt this:

    'but we always gave our very best to provide each patient with individualised and holistic care according to their present needs which could change very rapidly from one moment to the next and sometimes with only one registered nurse on duty. Every moment we were not engaged in other duties the dying patient, as well as their entourage, would always be our first priority and we did not need any clinical pathways telling us how to do it.'

    However, when most of England's regions are writing in their guidance that 'a valid and applicable written Advance Decision refusing cardiopulmonary resuscitation (CPR) is legally binding, but a verbal refusal of CPR is not legally binding', etc, someone has got to get the NHS to sort out its EoL guidance !

    Unsuitable or offensive?

  • michael stone | 6-Jun-2013 10:34 am

    Anonymous | 5-Jun-2013 2:15 pm

    where I worked we relied on local laws, the law of the land, hospital policy and were guided by medical and nursing ethics and not by EOL guidelines. this is management speak and something fairly recent.

    NHS management seem to have total influence over their clinical staff which appears to stifle their professional judgements and autonomous rights to decide with patients and their families what is best and most appropriate for each of them as individuals.

    In the UK healthcare appears to have turned into utilitarian supermarket, self service style, take it off the shelf or leave it practice, where the staff are obliged to follow the 'guidance' as you call it like sheep and not follow best practice and their own common sense from years of clinical experience acquired by themselves and from their colleagues!

    Unsuitable or offensive?

  • michael stone

    Anonymous | 6-Jun-2013 12:11 pm

    It is the law, and related logic, that current clinically-authored guidance screws up, as it happens.

    I think you are agreeing that a torrent of 'protocols' prevents staff from using common sense and expertise - I agree, and that issue is complicated (it depends on how expert the staff are: we get tick-box guidance, on the theory that it usually works even if staff are not very expert - sadly, it fails disastrously in very unusual situations).

    My issue, is that current protocols around things like resuscitation (being written by the regions - the GMC, I'm fairly sure, understands the law properly but is less than clear in its explanations) and Advance Decisions, are demonstrably (if you actually read the law itself and think) wrong: I'm not blaming operational clinicians for following dodgy protocols, I'm blaming, and arguing with, the people who are writing these protocols !

    But, there are also other issues around things like the LCP - a consultant commented to me recently that some cultures just do not accept 'dying' (he said some Americans seem to regard dying as almost voluntary), and some will not talk at all about what I call 'the dying bit'. As I'm concerned with EoL death at home, if people don't talk about the dying bit, or talk 'by implication', then combine that with 'earlier than formally 'expected' death', the way police think, the reluctance of coroners to discuss things (such as the point of 'expected death'), the fact that events can happen much faster than records can be updated, and the currrent situation is hugely unfair on live-with relatives of EoL patients.

    Things should be fair for everyone: for patients, and also live-with relatives, HCPs and even (although I'm not impressed by police 'thinking') the police. This requires 'fair balance points' and in turn, the creation of fair balance points means that patients and their relatives must also be tugging on the rope, not just the professionals.

    Bit of a rant - finished for now.

    Unsuitable or offensive?


  • michael stone | 6-Jun-2013 3:38 pm

    Anonymous | 6-Jun-2013 12:11 pm

    we didn't do tick boxes either but we all supported one another and especially those with less experience and all learnt from each experience as every one is entirely different, as with the care of any patient. no two cases are exactly the same even though some of the very basic care and procedures are.

    as far as the police are concerned they do not need to be involved for any natural death but in your unfortunate circumstances, and wherever they get involved with patients in the community they need more training to handle such cases more rationally and with greater sensitivity. here again, as in medical/nursing care common sense should be allowed to rule over protocols in some instances according to the given circumstances but then in a litigious age life is becoming more complicated.

    Interesting your comment about the USA, but then they also have the option of going into a deep freeze and emerging at a later date of their choice provided the protocols are followed and the tick all the right boxes!

    Unsuitable or offensive?

  • michael stone

    Anonymous | 6-Jun-2013 4:19 pm

    Interesting.

    'wherever they (police) get involved with patients in the community they need more training to handle such cases more rationally and with greater sensitivity.'

    I agree with you - but the police don't, so far as I can glean from those I've managed to discuss this issue with. Huge issue with the terminology of 'expected/unexpected' death, too long to dicuss here.

    'they also have the option of going into a deep freeze and emerging at a later date of their choice provided the protocols are followed and the tick all the right boxes!'

    I deduce that you are a fellow cynic.

    Unsuitable or offensive?


  • michael stone | 7-Jun-2013 9:51 am

    Anonymous | 6-Jun-2013 4:19 pm

    I am not a cynic although could rapidly become one reading all the recent negative press and some of the comments.

    I can just rest assured, as I have outlined in my previous comments, that I worked in a service where we always gave the very best we could and am grateful not only for all that I learned and was able to contribute but also it was far away from the current attitudes associated with reports about the NHS, although I have great fears of landing up in some of their services as a patient.

    as far as dealing with the police or any other authorities, there should be adequate training, professionalism to do the job people are assigned to and mutual respect, and people should be able to communicate adult to adult and not parent or adult to child as seems to have been your case and possibly many others (according to transactional analysis theory). the police also need to understand the effects of shock on relatives at difficult and traumatic times. Just like the instance when a mature middle age consultant friend of mine from the local hospital had his very old wheelbarrow stolen and reported it, not because of his loss, but only because there had been a recent spate of burglaries in his neighbourhood. One the phone they appeared quite disinterested but he felt he had done his bit. Then to his surprise, he got a phone call some time later asking him if he would like to have some psychological counselling! How about that for a compassionate service, which demonstrates so little common sense and probably wastes considerable resources (which might have have been put to better for something like additional training) - but I guess box ticked, job done which is easier as it requires little reflection, pleases the managers and probably helps with positive evaluations and incentives if it looks good on paper!

    Unsuitable or offensive?

View results 10 per page | 20 per page | 50 per page

Have your say

You must sign in to make a comment.

Related images

Related Jobs

Sign in to see the latest jobs relevant to you!

newsletterpromo