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Colleges and charities defend end of life care pathway

More than 20 organisations have signed a statement seeking to rectify “misconceptions and often inaccurate information” about the Liverpool Care Pathway for the dying patient.

The group of charities and royal colleges said accusations that the pathway was a way of withholding treatment, including hydration and nutrition, risked detracting from the “substantial benefits” it could bring to patients.

For example, in June newspapers quoted a doctor as saying it had become an “assisted death pathway rather than a care pathway”, with pressure on hospital beds leading to older patients being put on it too early.

The group have signed a consensus statement to provide “clarity” about what the pathway “is – and what it is not”. Signatories include the Royal College of Nursing, Marie Curie Cancer Care, Macmillan Cancer Support, and the National Nurse Consultant Group (Palliative Care).  

The statement says the pathway is a framework for good practice, which “does not replace clinical judgement”. It requires staff to ensure all decisions to continue or stop a treatment are taken in the “best interest of each patient”.

The pathway should not “hasten or delay death”, but ensure the right type of care is available in the last days or hours of life “when all of the possible reversible causes for their condition have been considered”, the statement adds.

RCN long-term conditions adviser Amanda Cheesley said: “We want to make it clear that it is not in any way about ending life but about supporting the delivery of the best possible end-of-life care.”

Readers' comments (44)

  • MeThinks

    “best interest of each patient”.

    The issues involve the definition of what that phrase means. And also exactly what the following one means:

    “does not replace clinical judgement”.

    Lack of clarity about those, leads into a legal minefield!

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  • any guidelines are only as good as those who apply them!

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  • Where is the lack of clarity? The Liverpool care pathway is used for end of life care when all reversible causes have been exhausted. It is not withdrawing care, it is ensuring all care is clearly documented. All staff need to agree for the patient to go on it and it is not used to hasten death, but to ensure they have a dignified death!

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  • michael stone

    Anonymous | 1-Oct-2012 11:40 am

    One issue over clarity, is how one would define 'being on the LCP'. A second point, is you didn't make it clear if patients need to agree to being on the LCP ? And there is a fundamental difference between care and documentation. Who decides what amounts to 'dignified' ?

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  • The LCP is in integrated care pathway, it is used instead of documenting in nursing and medical notes. The principal behind it will be discussed with the patient (if appropriate) and their family. You can define dignified how u please. As long as you feel you have done your best for your patient in the last days of life. Perhaps you need to speak to your palliative care team for some education on the issue.

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  • Anonymous | 1-Oct-2012 11:40 am

    "All staff need to agree for the patient to go on it"

    and the patient ...?

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  • It is discussed with the patient if appropriate.

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  • michael stone

    Anonymous | 1-Oct-2012 2:23 pm

    Anonymous | 1-Oct-2012 2:56 pm

    I wasn't Anonymous | 1-Oct-2012 2:37 pm
    by the way - the issue is

    'It is discussed with the patient if appropriate.'

    who decides 'if it is appropriate' ?

    And 'dignity' should normally be the patient's concept of dignity, not anybody else's concept of dignity.

    There are some legal issues here, which I've outlined in other places on this site: legally, it seems pretty clear that clinicians do not decide what 'best interests' mean, and that capable patients have to give permission to be treated (on a treatment-by-treatment basis) - if the patient can't do that, then the law does not say 'clinicians decide and have the final word' {even if some clinicians think the law does say that}.

    And a question re Anonymous | 1-Oct-2012 2:23 pm:

    'Perhaps you need to speak to your palliative care team for some education on the issue.'

    To which poster, was that comment addressed (it seems specific) ?

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  • Writing as a journalist (Catholic Herald) on the LCP, I described it – following chats with experts and reviewing the reports – with general approval. Of course I was attacked for my pains – the usual stuff, and from doctors. However I did make the point that abuse of LCP was possible, and that the patient or relative should ask to see the hospital’s protocol, and should then reassure themselves by discussing it with a competent person. I recommended that any hospital not being willing to do this (or answer any question of concern) should immediately require a second opinion. I think it’s important, even if the large majority of hospitals are punctilious, to be aware that this is not 100%.

    The public are often afraid of medical staff; they may even believe that if they make trouble their relative will suffer.

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  • I guess it's not 'appropriate' to discuss the LCP or any other care with a patient who is unconscious or so near death that a discussion would be very distressing for them.

    Acting in the patients best interests is what doctors do, whether it's saving someones life or withdrawing futile treatment. No-one ever accuses a doctor of 'playing God' when a patient survives, despite what the patient might have wanted given the choice.



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  • tinkerbell

    Quentin de la Bedoyere | 1-Oct-2012 6:00 pm

    'The public are often afraid of medical staff; they may even believe that if they make trouble their relative will suffer'


    Sad but true.There would also be very few relatives who would ask or even know about protocols/policies to which they could refer to have an informed opinion on the matter.

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  • Appropriate would mean whether the patient was conscious enough to be able to have a discussion, a lot of patients on the LCP are completely unresponsive and unconscious.

    I do wonder whether people commentin on the LCP have actually looked at the documentation and read it.

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  • Anonymous | 1-Oct-2012 2:56 pm

    "It is discussed with the patient if appropriate."

    what is deemed appropriate?

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  • Why should we have to clarify and justify our professional tools based on the misconceptions, bent truths and often downright lies of the mass media?

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  • The well publicised LCP is available to read on-line for anyone interested.

    I wonder how many people totally opposed to it's use have seen the distress caused to patients when doctors and nurses attempt to put cannulas or butterflies in patients whose bodies are bruised and swollen or try and pass ng tubes in patients who resist or continually pull them out. We don't give patients anything orally if they cannot swallow except good mouthcare and maybe a tiny piece of a lolly.

    Can one of these experts out there please explain to me how giving sub-cut or IV fluids eases thirst?

    Can someone also explain to me why they would like to be 'kept alive' for just a few days more at all costs, given antibiotics that no longer work and may just cause diarrhoea and sickness or given IV fluids that just make their arms swell even more.

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  • Anonymous says: Why should we have to clarify and justify our professional tools based on the misconceptions, bent truths and often downright lies of the mass media?

    I hope this contributor is not as arrogant as he or she sounds. We live thankfully in a society where we do not need to be talked down to by our 'betters'. Who has got the greatest interest in whether LCP is being used properly - the medics or the patient (and relatives)?

    As a matter of fact most of the public criticism of LCP has come from doctors.

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  • MeThinks

    Various posters have pointed out that an unconscious patient cannot be asked - the issue then usually moves to the Mental Capacity Act and what section 4 means: the question is must people who might reasonably be able to act as 'proxy minds' for the particular patient, be asked - and, is any particular individual empowered to 'impose' a section 4 best interesrts decision ?

    I can answer last question for you - a single suitably-empowered welfare attorney can effectively impose a best interests refusal of a treatment.

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  • A new article on LCP to be found on the internet today.
    http://www.dailymail.co.uk/news/article-2211484/Two-doctors-agree-use-controversial-death-pathway-patients-final-days.html?ito=feeds-newsxml

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  • aren't people allowed to die any more? we have to accept that everyone dies, it happens to our patients, their relatives, us, our relatives. Medicine can cure people but it can also prolong the inevitable.

    I do not want the staff to have to bring in an advocate to assess my best interests when I only have a few hours left. I'd rather spend them in a blissfull pain free quiet environment. I don't want my relatives coming in to see me with litres of oxygen blasting through my face, drips bleeping, pieces of gauze covering my arms from failed cannula attempts.

    Some people seem to think that one minute you're walking around the ward, chatting away feeling fine then boom you're on the LCP. It doesn't work like that.

    Has anyone here been asked to 'keep IVABs, IVI, ng feeding, oxygen going until the relatives get here in a few days" - is that dignified and working in the best interest of the patient - no, it is not.

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  • I think the doctors who accused their colleagues of using the LCP to free up beds should issue an apology and justify their unkind and untrue comments.

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