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Axing of Liverpool Care Pathway branded 'illogical'

The decision to axe the controversial Liverpool Care Pathway (LCP) is “illogical”, a senior end-of-life doctor has said.

Scrapping the care pathway is a “tragedy”, palliative care consultant Claud Regnard said. He suggested the LCP was a “scapegoat” and compared the decision to replace it with banning the Highway Code because of bad drivers.

In July it was announced that the measure would no longer be used after an independent review concluded doctors had used the LCP “as an excuse for poor-quality care”.

The review panel, chaired by crossbench peer Baroness Neuberger, said they were “shocked” and “upset” at some of the “distressing” cases of appalling care.

Patients were left on the pathway for weeks without any review and some patients’ families were even shouted at by nurses for giving them water.

In response, care and support minister Norman Lamb ordered all NHS hospitals to undertake reviews of care given to dying patients. He also ordered hospital bosses to ensure that in the future every patient has a named senior clinician responsible for their care in their final hours and days of life.

Financial incentives to put people on the regime would also be scrapped, he added.

Writing in Age and Ageing, the journal of the British Geriatrics Society, Mr Regnard said: “The death of the Liverpool Care Pathway was preventable, an irony that was lost in the rush to pronounce its demise and promote the message of a listening government.

“It is as logical to discredit guidance because of errant clinicians as it is to ban the Highway Code because of bad drivers.”

He added: “The Neuberger report failed to show that the Liverpool Care Pathway was the cause of poor end-of-life care and made it the scapegoat for poor communication and faulty decision-making.

“The report’s discrediting of a quality assurance mechanism that had the potential for improvement is a disservice to dying patients.”

 

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Readers' comments (19)

  • Care Homes performing Pathway need even more oversight!

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  • Ellen Watters

    I totally agree, and shame on the Nursing Times for quoting the same sensationalist, negative, inaccurate text as the tabloids about food and drink withdrawn in the last hours or days of life.

    A few who lacked proper training or who didn't use the pathway properly were culpable for its demise.

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  • What a travesty. I helped to implement the LCP into the hospital where I work. Used correctly it was an amazing tool that took the guess work out of the last few days of a patients life. Admittedly, human nature and its indominatable fight for life sometimes confounded us and those patients were taken off it. It was never set in stone and relatives and patients (if able) were always told this. Once again, a knee jerk reaction to bad care given by a few health professionals.
    I will not say that it was perfect, but it gave us a chance to care differently, to be gentle instead of intrusive and give some genuine TLC instead of trying to put a cannulla into some poor old ducks, dry, collapsed veins. We never had a rule to say that if they wanted a drink they couldn't have it, mouth care and hygiene needs still counted for everything. Nicer for the relatives as well, they had a chance to see their loved ones at peace and not poked around so much. In all honesty we haven't used it for a little while here as I think people were a bit alarmed by all the alarmist media attention it got. We now seem to be in limbo trying to do the best for our dying patients, but not sure how to go about it without the documentation to back us up.

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  • michael stone

    Now I'm puzzled - I thought Claud had retired by now, based on an e-mail he sent to me in January.

    The LCP, for one reason or another, all too frequently led to confusion between the efficiency of a treatment and whether it had been consented to, and it very clearly did not properly address (or explain) some issues about decision-making during periods when patients have lost mental capacity. Something not peculiar to the LCP, amongst clinically-authored guidance.

    melanie campbell | 17-Dec-2013 1:51 pm

    You write:

    'Used correctly it was an amazing tool that took the guess work out of the last few days of a patients life.'

    That was the problem - seeing the LCP 'as a plan' instead of seeing it as a set of available options, with the chosen options sometimes differing from patient to patient even in identical CLINICAL situations.

    Claud has written widely about the MCA and other EoL issues - we are not in complete agreement, about what the law means. In particular, we disagree about verbal refusals of possible future treatments, expressed by mentally-capable patients during an ongoing clinical situation, but not written down as an Advance Decision: Claud claims they (verbal refusals) are not 'legally binding' and I say Claud is misunderstanding the Mental Capacity Act and the purpose of written ADRTs.

    Going back to Melanie, this reminds me of something I commented on to Tessa Ing, when we were discussing the LCP:

    'Nicer for the relatives as well, they had a chance to see their loved ones at peace and not poked around so much.'

    Tessa said 'one advantage of the LCP, is it tells clinicians to stop taking unnecessary blood samples, etc' I told Tessa, that if I were dying and still mentally capable, then I would forbid clinicians from using me as a human pin cushion and taking blood samples, unless I could see some advantage to me - which seems unlikely, if I was 'dying' (and even less likely if I were on the LCP, which claimed to not shorten or lengthen life - if those blood samples were not to extend my life, why would I allow them to be taken ? If clinicians were trying to extend my life, I couldn't be on the LCP by definition.).

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  • I was initially so pleased to read that headline.....what a disappointment that youve written such incorrect information. Where in the LCP does it recommend withdrawing treatment, food & water from sedated patients? Good end of life care needs good education & training, not well respected sources such as the Nursing Times publishing such incorrect information.

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  • Totally agree. LCP was improving care in my setting and it's loss has undone a lot of hard work in changing doctors attitudes to EOL care. The irony is the trusts replacement guidelines are virtually identical to the LCP framework.

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  • Well it was trial by media for the LCP and we all know we must do what the media decide don't we?!

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  • grumpy

    Michael stone - who and what are you exactly?
    Read many of your comments and you surely cannot be a practising nurse

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  • michael stone

    grumpy | 17-Dec-2013 11:25 pm

    I'm an annoyed ex family-carer, who isn't at all happy with what many clinical authors are writing about the 'meaning' of the MCA, and neither am I happy with contemporary guidance for EoL (as in 'final yea rof life') patients who are at home and arrest at home (especially those patients who arrest 'unexpectedly' [to be more technical, before 'expected death'} directly from mental capacity, and who would not want attempted CPR irrespective of why they arrested).

    I'll put a few links up later, then if you care to you will be able to work out 'who I am'.

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  • michael stone

    Hi Grumpy, the following would let you understand 'where I'm coming from', I think.

    You can download my submission to the Neuberger Review of the LCP from the first post at this link (anyone can download files from that website, although to post a comment you need to join it), and I started my submission with a quick explanation of how I'm involved:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=676&forumID=45

    The following are links to two pieces of mine in BMJ online - again, they should make it clearer 'where I am coming from':

    http://www.bmj.com/content/347/bmj.f4085/rr/652862

    http://www.bmj.com/content/347/bmj.f4085/rr/654490

    The second of those two pieces, is the one I regard as 'the more fundamental', although the first is easier to understand.

    I hope that answers your question ?

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  • Havent time to see all your links but you are obviously a very well read and concerned person. If you had talked to as many relatives about the care of their loved ones in hospital, you would understand the reasons why LCP iis withdrawn. It is a death pathway. Ones who have been taken off, at request of relatives or clinicians, have recovered. The problem is that the elderly only go into hospital as a last resort (afraid to) and are at a very low ebb. They have the medical condition addressed but they are weak, under-nourished and then suffer dehydration from lack of CARE. No one bothers whether they have drunk their water, tea, whatever and so they become a bit confused, dizzy and may run a temp. They are then confined to bed and this is a criteria for being put onto the pathway. No blood test can then be done to see if they are dehydrated and all treatment stopped. If they cant drink, through confusion etc. they dehydrate further and soon have to be sedated to stop them getting out off bed and falling, or rambling. Its a vicious circle. If they HAD been dying, I doubt the GP would have sent them in. He/she sent them in for treatment. Obviously some are dying and nothing will revert the process but they do not need to die of thirst, endure painful pressure sores or suffer a high temp due to lack of fluid which prevents sweating and removal of toxins in urine. I have nursed and sat with many dying people and very few have been in pain or needed sedation, yet on the pathway they ALL have to have morphine and madazalem (sedative and respiratory represent.) In proper pain management the 1st choice is neither of those two. The right pain-killer is sought and lowest dose to "Get in front of the pain". If an increase is nec this is titrated and increased as nec. Diamorphine is the last resort in sever uncontrolled pain but even that can be at a lower does than LCP if used with an adjvant, depending on the sourse and type of pain. In Hospices, patients are kept pain AND symptom free and remain alert and responsive until almost the end. This is proper, individual palliative care-its a time when relatives/friends can put right any wrongs, patients get their affairs in order and can be a positive, rewarding time. How a person dies sticks with the people close FOREVER.In most LCP patients, the relative doesnt even know that their loved one is on it or that the certain outcome is death. I am glad the Gov are insisting food and drink be given as long as desired and tolerable. Should they need to say that?

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  • Sally, you sound like a very nice person but have you ever actually seen a copy of the LCP, your post is wrong in nearly every single aspect that you are presenting as fact! It does not state that every patient on it HAS to have morpine or midazolam and it certainly does not give a dose. You say that every patient removed from the LCP has recovered - where is your evidence i'd be very interested to see the stats. Food and drink are given as long as tolerated or desired. The elderly dont only go into hospital as a last resort again i think you vastly over generalising. As a nurse in a community hospital i have always been a big supporter of the LCP as it enables us to give the best quality care at end of life but i do think that in some of the Acute hospitals it hasnt always been communicated properly as it does require a lot of time to be spent with patient and their relatives explaining the process which unfortunately isnt always possible in such a busy environment.

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  • michael stone

    Anonymous | 18-Dec-2013 10:09 pm

    I find this interesting:

    'As a nurse in a community hospital i have always been a big supporter of the LCP as it enables us to give the best quality care at end of life but i do think that in some of the Acute hospitals it hasnt always been communicated properly as it does require a lot of time to be spent with patient and their relatives explaining the process which unfortunately isnt always possible in such a busy environment.'

    Why, if 'it isn't communicated properly' to patients/relatives, do the involved clinicians consider that they have satisfied the law re Informed Consent and section 4 MCA best interests decision-making ?

    Informed Consent does require the transmission of the necessary clinical information about outcomes BEFORE the patient consents, and section 4 of the MCA (a very 'hotly' disputed issue) also requires something very similar !

    But of course most patients removed from the LCP should still die, if they were not inappropriately placed 'on the LCP: it is also true that some (a small percentage) patients correctly placed on the LCP, should recover and live (because of clinical uncertainties).

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  • michael stone

    sally carson | 18-Dec-2013 2:50 pm

    Sally, I don't talk to relatives - but the Neuberger Review was clear about the unacceptably high prevalence of the things you mention.

    And you are spot-on:

    'This is proper, individual palliative care-its a time when relatives/friends can put right any wrongs, patients get their affairs in order and can be a positive, rewarding time. How a person dies sticks with the people close FOREVER.In most LCP patients, the relative doesnt even know that their loved one is on it or that the certain outcome is death. I am glad the Gov are insisting food and drink be given as long as desired and tolerable. Should they need to say that?'

    They shouldn't need to say that, pretty obviously. But the problems stem - and you pointed this out - from MDTs behaving as if patients are 'OUR patient' instead of properly involving family and friends. Or, sometimes, from EVEN NOT ASKING THE PATIENT !



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  • Carson & Stone
    Talking out your bottoms as usual. I stopped using this site because of the sh!te talked by Mike, shall have to reconsider my decision dependant on the answer to my next question:
    Mike Stone, what is the LAW on CPR in this country? ( Last time I posed this to Mike he told me that I hadn't understood my own question!).
    By the way, every trust still keeps the LCP, they have just given it a different moniker, because clinicians with a real idea know it works. The reason why people survive after being taken off the pathway is because it doesn't harm you. It is not the medical equivalent of a bullet to the brain, that's what happens at Dignitas or iin Texas when they execute men with the IQ of children.
    ( Cue Mike telling me I don't know what I am on about, because he is a scientist with many years experience of stalking a nursing forum, as well as loads of " quotations" taken out of context that are meant to show how deeply he understands the subject compared to the rest of us.)

    Merry Christmas.

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  • michael stone

    redpaddys12 | 24-Dec-2013 4:28 am

    Hi Red - not sure how we got from the LCP to the law about CPR ? The law about CPR is the same as the law for any other intervention, and it is basically:

    1) If you understand (and the point is 'understand' - this stuff about a refusal of CPR needing to be written to be legally binding, because a valid Advance Decision refusing CPR must be written, is a confused over-simplification which is nevertheless held as a truth by many clinicians) the patient has refused the intervention [under the circumstances of the particular CPA, and when of mental capacity] then attempted CPR is legally an assault.

    2) If someone arrests 'genuinely suddenly' then you can attempt CPR (and clinicians who don't attempt CPR are likely to get into trouble - especially paramedics) unless you know that the patient has forbidden it (which is still possible).

    3) If someone loses mental capacity as a separate event from entering CPR (for example has had dementia for years) then the law becomes tricky, because we are then into Mental Capacity Act territory, and there is some dispute about what the MCA 'says'.

    That is the concise version - the complexity is mainly in point 3.

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  • michael stone | 28-Dec-2013 2:17 pm

    go back to sleep. it was peaceful on this site without your nonsense the last few days.

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  • the result of government- and managerial- led decisions as opposed to patient-centered clinical expert ones. nothing will change and the failure of patients to benefit from best evidence-based practice will continue as long as clinicians have their professional autonomy curtailed and are not listened to. perhaps they should just all receive less and cheaper training so that they can just act like muppets and moppets and do as they are told offering patients supermarket style care based on guidelines rather than expertise with carefully designed plans to meet their individualised needs. cheaper perhaps in the short but with more costly long term effects at serious personal detriment and cost requiring heftier investments in the long run in their future needs to try and recover the bits and pieces left of them!

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  • michael stone

    Red, a rather fuller answer to your CPR question can be found as 'poser no 6' (you will need to scroll down to it) at:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=692&forumID=45

    Feel free to regisater wqith the website, and to explain where I'm wrong.

    I extend the same invitation to Anonymous | 28-Dec-2013 3:59 pm - I like to read reasoned explanations of why I'm 'talking nonsense' (but find them hard to obtain).

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