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Practice comment

"Understanding the Liverpool Care Pathway is essential"

More than 20 organisations, including the Royal College of Nursing, recently signed a statement seeking to rectify misconceptions and inaccurate information about the Liverpool Care Pathway for dying patients.

The aim of the LCP is to help professionals, in partnership with their patients and families, clarify what care and support individuals want at the end of life. This includes conversations about treatment to alleviate distressing symptoms, as well as nutrition and continence care.

Yet claims by a doctor earlier this year that the LCP was an “assisted death pathway rather than a “care pathway” received extensive media coverage. It was suggested that older people were placed on the pathway early in a bid to relieve pressure on hospital beds.

The consensus statement makes it clear that the LCP should never be seen as a means to ration treatment or withhold care. The tool was developed to support best practice, and should be used only when the multidisciplinary team has agreed their patient is dying and there are no interventions that would reverse this.

It aims to clarify the decision of the team and, if possible, the wishes of the individual and records all the information in an integrated care plan. This should not be confused with other palliative care documentation such as Preferred Priorities for Care and advanced decisions to refuse treatment.

Most of the misconceptions and poor experiences during end-of-life care can be traced to poor communication. The LCP can be used to improve this as it focuses not only on diagnosis and treatment but also the spiritual, religious and cultural needs of the patient and their families. By identifying the changes that might be expected as the end of life approaches, information can be shared and communicated to ensure there are no surprises or misunderstandings.

Nurses are usually the people who have the most contact with patients and families so need a clear understanding of the LCP, when it can be used and its benefits. They need to ensure that patients and their families understand their role in developing care plans. Nurses need to develop and use their skills in communication, decision making, assessment and compassion as well as their clinical skills, to support the best possible end-of-life care.

Critical to the successful use of the LCP is training so staff understand its purpose, are confident to have complex conversation with patients and their families about care, and have the skills to record this accurately.

The use and implementation of the LCP should not be viewed as something that is only used in specialist areas by specialist teams. It can be used by any professional in any area. If it is used as it should be, the lasting memories of those who have been bereaved will be positive.

It is not in any way about ending life but about supporting the delivery of the best possible end-of-life care.

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Readers' comments (33)

  • could NT please publish the report where doctors accuse their colleagues of placing patients on the LCP to free up beds.

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  • Or the several hundred articles in the daily mail accusing staff of euthanising patients

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  • We need a serious debate about the use of the LCP and the benefits to patients........doctors will be afraid to use it and patients will suffer!

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  • just sounds like a form of Euthanasia to me !!!!

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  • Anon 12.50pm
    The pertinent phrase is 'sounds like'. Believe you me, its not. People can be on the LCP for a number of days, go to Dignitas and its over in 20 minutes.

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  • The LCP is discredited in the eyes of the general public.

    Headline which scream about old people being denied "food and water" or "starved and drugged to death" are commonly seen and have a achieved a degree of credibility.

    The term LCP should be removed from the vocabulary of Doctors and Nurses.

    In the absence of an "end of life directive" patients and their relatives should be informed of what is and what is not possible in clear and unambiguous terms by a senior clinician.

    If a patients prognosis is poor this should be spelt out clearly without the use of euphemism.

    Patients / Relative should CHOOSE the care to be given and sign a consent which details the risks of the treatment they choose. ie Inhalation pneumonia. cardiac overload etc.

    The analgesic ladder should be explained and an option given to refuse any and all opiate medication. Similarly an indication of how the patient/relatives want distressing confusion managed - the option to refuse drugs like Medazolam must be given.

    Power must and should be given to patients/relatives. They should choose the care to be given and they MUST understand they are accepting full responsibility.

    It will not be long before the patients/relatives and other detractors reinvent the LCP and begin a campaign for its re-introduction!

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  • I work in a hospice and use the LCP regularly. The LCP is a guide to care and not written in stone it is reviewed officially every three days.Some patients may be on the LCP for weeks,some patients if stabalise come off the LCP. It is a guide to best care and definitely not as has been previously stated a form of Euthanasia.

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  • Charlotte Peters Rock

    "The consensus statement makes it clear that the LCP should never be seen as a means to ration treatment or withhold care. "

    So it says above. But what about forcing unwanted and unnecessary treatment (no care though) on the old.. as happened nearly nine years ago to my father, Ralph Winstanley in Doncaster.

    No expense (except washing, care of pressure points and the truth) was spared in his case. Unfortunately he had not been dying, as his two Consultants have clearly stated to us in writing.

    Nearly nine years later, we are still trying to get the woman who drove this killing by her continuous - and well recorded - lies, into jail where she belongs.

    And the NHS? It has helped the cover up for all that time. Perhaps had not the Chairman of the PCT at Doncaster been an ex-senior serving police officer at Hillsborough, we might have had more joy.

    As it is, our own lives have been ruined as well.

    Thanks NHS!

    And the GMC? - total cover-up!

    And the NMC? total cover up - and defamation by the so-called investigation officer.

    Thanks M M!

    And the police? Aah, don't ask..

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  • Yes But

    The Mail is having a go at the LCP today, as it happens.

    The fundamental issues involve patient consent and who makes what decisions - complicated legally and not well-described at present.

    The LCP is about caring for dying patients, and all of these negative comments indicate a problem, somewhere. Usually problems hinge on consent and communication, and who can decide what.

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  • michael stone

    Here I go again.

    Anonymous | 14-Oct-2012 5:05 am

    There is a difference between not wanting to make a decision which you can legally make, and not being properly given the chance to make a decision that is legally unambiguously yours to make. A significant difference.

    Also, patients can alter their minds about treatments whenever they wish to: so a refusal of pain relief today, does not mean I cannot accept pain relief tomorrow.

    As for your:

    'Power must and should be given to patients/relatives. They should choose the care to be given and they MUST understand they are accepting full responsibility.'

    the position of patients is different from that of relatives, the legal positions are different if a treatment has been offered as opposed to requested, and it all gets very complicated if patients lapse into mental incapacity (even, because the guidance is currently wrong, if an appropriate Advance Decision has been created, or if you have clearly expressed your decision to your clinicians).

    But if patients make a decision which is within their power, then clearly that is their decision - there is not then any responsibility left for clinicians to accept or otherwise.

    This is about who can make what decisions when, and who must be informed of what when: it isn't really about the sensible objective of the LCP to make dying less distressing, it is about the decision-making process, and issues about who can legally decide what. Until you throw in certain religious complications, certain inevitable complications when you think through the problem of multiple decision makers (which the MCA definitely leaves, despite the Code attempting to 'fudge' this issue), and the complication introduced by section 4(5) of the Act combined with a resource-limited healthcare system.

    There is also a complication around patient confidentiality.

    But you cannot be sure of your conclusion:

    'It will not be long before the patients/relatives and other detractors reinvent the LCP and begin a campaign for its re-introduction!'

    until you have properly involved non-clinicians in end-of-life care.

    Personally, having watched a friend die from cancer, I would quite like to know that permanent deep sedation would be available if requested by patients: HCPs are, it seems, unable to give an unequivocal answer to that one.

    Charlotte Peters Rock | 15-Oct-2012 2:13 pm

    The PHSO is pretty hopeless too - and I agree with you, it causes enormous trauma to bereaved relatives when things go wrong, and 'the system' then covers its own back.

    But it is complicated. And the guidance about EoL care is improving, although I still beleive it is in some places legally flawed.

    However, if people appointed Welfare Attorneys, certain problems would be removed - although that takes time and money, and is not a complete solution.




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  • Charlotte Peters Rock

    "The consensus statement makes it clear that the LCP should never be seen as a means to ration treatment or withhold care. "

    So it says above. But what about forcing unwanted and unnecessary treatment (no care though) on the old.. as happened nearly nine years ago to my father, Ralph Winstanley in Doncaster.

    No expense (except washing, care of pressure points and the truth) was spared in his case. Unfortunately he had not been dying, as his two Consultants have clearly stated to us in writing.

    Nearly nine years later, we are still trying to get the woman who drove this killing by her continuous - and well recorded - lies, into jail where she belongs.

    And the NHS? It has helped the cover up for all that time. Perhaps had not the Chairman of the PCT at Doncaster been an ex-senior serving police officer at Hillsborough, we might have had more joy.

    As it is, our own lives have been ruined as well.

    Thanks NHS!

    And the GMC? - total cover-up!

    And the NMC? total cover up - and defamation by the so-called investigation officer.

    Thanks M M!

    And the police? Aah, don't ask..

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  • michael stone

    Anonymous | 14-Oct-2012 5:05 am

    You wrote ‘in the absence of an end of life directive’ – a lot of complexity is tangled up inside ‘end of life directive’.

    Dignity In Care has, after some delay, made a file containing 3 ‘surveys’ I carried out, downloadable from:

    http://www.dignityincare.org.uk/Discuss/forum/?forumID=45&obj=viewThread&threadID=667

    Starting on page 16, you will find a survey investigating what people believe an Advance Decision is (or, at least, an issue involving ‘circumstances’ on ADRTs) – a patient cannot even rely on a written Advance Decision, because what many clinicians believe is true for ADRTs, is not what section 24-26 of the Act states.

    And a valid written ADRT is a legal instrument, unlike a care plan – it is all something of a mess !

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  • I remember reading the mentioned article by the doctor and I was very upset about it. While I agree that the LCP may be used inappropriately at times (in the same way that Antibiotics are used incorrectly, Painkillers etc, although LCP is on a much more significant scale given it's importance), I believe it is used appropriately the majority of the time.

    I guess it was always going to end of some controversy once the NHS implemented it. I have worked for the last 12 years in Cardiology (5 in last post, 7 in current) and in my first post, looking after a patient at end of life was not very common and so I always struggled with what was best for the patient and how best to be an advocate for them when needed. In my current post, it is quite common to have patients dying on our ward and I find the LCP as a very useful adjunct to the care I give. They are always implemented, when appropriate, with the appropriate professionals (Palliative Care Specialist Nurses, doctors etc) and the patient, if possible, and their families. On a busy ward it is sometimes difficult to remember to regularly assess the patient for pain, discomfort, distress etc, so the Pathway is a good reminder of it. I now feel much more confident in looking after my patients, making decisions and querying decisions if I don't feel they are correct. Our patients on the LCP are always assessed medically at least once a day, sometimes more. I have actually yet to be in a position where a patient on the LCP improves enough to be taken off the pathway so, I consider that as a good indicator that the decisions we make are the correct ones.

    I guess the most vital part of the LCP is effective and complete communication with the patient (where possible) and their families, combined with the necessary health professionals.

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  • eileen shepherd

    This is the link to the original news story published in July.

    http://www.nursingtimes.net/home/end-of-life-care-pathway-used-to-cut-costs/5046868.article

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  • michael stone

    nursemorph | 16-Oct-2012 1:41 pm

    'I guess the most vital part of the LCP is effective and complete communication with the patient (where possible) and their families, combined with the necessary health professionals.'

    That is the bit where most post-mortem complaints stem from - relatives not being 'kept in the loop' (I think it better to have pre-mortem disagreemetns, rather than non-discussion and huge arguments after death).

    Not quite on the LCP, but on the same general area, I sent an e-mail to Prof Hugh Montgomery after he recently appeared on Radio 4's 'The life Scientific', and yesterday I asked him if I could distribute his reply to me, and what he sent in reply to that question is interesting: it touches on many of the issues, and Hugh and I both think 'get decisions from the patient' is the right approach (so far as I can understand).

    Here is Hugh's e-mail:

    Hi, Michael.

    Do feel free to pass on my comments if they help.

    Trying to maintain compassion in a world of documentation and litigation is indeed feeling harder. I also recognise that the days when doctors 'did what they thought best without discussion' had to go...

    That said, my faith WAS restored at the weekend when an elderly lady made clear that she wanted treatment withdrawn. Her family spoke with her and supported. I took the 'tight mask' off, and she smiled with releif. We made her a cup of tea, which she drank with the help of her family. She closed her eyes, and a minute later died peacefully. A class act!

    With best wishes

    Hugh


    Prof Hugh Montgomery MB BS BSc FRCP MD FRGS FRI FFICM
    UCL Professor of Intensive Care Medicine
    Director, UCL Inst for Human Health and Performance
    Consultant Intensivist, Whittington Hospital
    GLA London Leader


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  • nursemorph | 16-Oct-2012 1:41 pm

    "I have actually yet to be in a position where a patient on the LCP improves enough to be taken off the pathway so, I consider that as a good indicator that the decisions we make are the correct ones."

    Could that be because you are witholding fluids and giving sedation? I took my brother off the LCP and he lived another 5 weeks. He was extremely grateful for this and he told his consultant this in no uncertain terms. As an experienced nurse I question things I am asked to do.
    Relatives are spoken to when they are in a state of shock and don't always comprehend what is being planned.
    Witholding fluids and dehydrating people until they die is not humane, if you did that to an animal you would be prosecuted.

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  • tinkerbell

    kathleen flanagan | 17-Oct-2012 1:10 pm

    I totally agree with you.

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  • 'kept in the loop' ???????

    what world do you live in. what do such expressions remotely have to do with patient care, support of their relatives and empathy? these are living human beings often coming towards the end of their life we are talking about for goodness sake! No wonder much of the compassion has allegedly gone out of patient care when it is reduced to mere management jargon! People writing like this should be banned from commenting on a nursing site.

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  • I agree with the article in D'Mail 5th Oct - Pressuming patients will die in a certain time, is very difficult, even when assessment tools are used, there are 60% wrong. Even if death seems imminent, there is no need for a Pathway. All Nurses should be trained to, 1st CARE for the dying and 2nd be trained in palliative care. Sedation is not always necessary but it is primary in LCP. Considering that these patients have come into an acute care ward, they have come in for TREATMENT. If they WHERE dying, the GP would not have sent them in-better to die at home, but these patients, if not responding quickly to treatment and usually have many chronic ailments, they are considered to be best off dead. Treatment is stopped, ie antibiotics and is most cases hydration. The infection must, if not treated cause extreme symptoms. These are masked by sedation. Is this killing, or letting them die, with a little push from dehydration and sedation?
    We need a full enquirey into and, hopefully, withdrawing of the LCP

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  • Michael Stone

    Anonymous | 17-Oct-2012 1:57 pm

    'kept in the loop' ???????

    "what world do you live in. what do such expressions remotely have to do with patient care, support of their relatives and empathy? these are living human beings often coming towards the end of their life we are talking about for goodness sake! No wonder much of the compassion has allegedly gone out of patient care when it is reduced to mere management jargon! People writing like this should be banned from commenting on a nursing site."

    Unsuitable or offensive?

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