Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

90% of doctors 'support Liverpool Care Pathway'

  • 28 Comments

“Ninety per cent (of doctors) would be prepared to be placed on the controversial Liverpool Care Pathway programme if they were nearing death” is the reassuring news in today’s Metro.

The Daily Telegraph strikes a more downbeat note with the claim that ‘fifth of doctors queasy about always telling relatives’. This view would go against official advice from care minister Norman Lamb that no patients should be put on the controversial Liverpool Care Pathway ‘without a proper explanation or their families being involved’.

Both reports come following an opinion poll of palliative care specialists, asking them about their views on the Liverpool Care Pathway (LCP).

Out of more than 3,000 UK doctors contacted during the survey (commissioned by the BMJ and Channel 4’s Dispatches programme), 563 with experience in use of the LCP responded.

The results of this survey were overwhelmingly positive, 91% of those who responded thought that the LCP represented the best care for a person who was dying and helped them to die with dignity. Also, 90% of respondents said they would be happy to be placed on the pathway themselves if they were dying.

What concerns have been raised about the Liverpool Care Pathway?

The LCP has been widely used for over a decade without attracting much attention. But in 2012 the LCP seemed to become a ‘hot topic’ for the newspapers, attracting a lot of coverage throughout the year.

Some of the coverage raised legitimate concerns, such as:

  • people may be put on the care pathway inappropriately
  • people being placed on the care pathway without discussion with the family and person themselves, if this is appropriate

While some of the coverage was downright lurid, with completely unsubstantiated claims that hospitals were putting people on ‘death pathways’ in a cynical attempt to save money and free up beds.

Criticism of the LCP in recent months has led to ongoing reviews by the Department of Health and the NHS National End of Life Care Programme.

How was the survey carried out?

The current media reports come following publication of an article in the British Medical Journal (BMJ) which reports on the findings of a BMJ survey conducted in conjunction with Channel 4’s Dispatches.

Last month, the BMJ emailed 3,021 UK hospital doctors asking them to participate in an anonymous online survey of their views on the Liverpool Care Pathway.

Only 21% of those invited to participate (647) agreed. Of these people, 87% had used the LCP, and these 563 doctors were included in the full survey.

They represent 185 palliative medicine consultants (roughly 40% of the UK total), 168 doctors in palliative medicine training posts, and 210 doctors in other specialties, but with some experience in palliative medicine.

What were the main findings of the survey?

The main findings reported in the BMJ article from the 563 doctors who completed the survey are as follows:

  • Over half of the 563 doctors (57%) thought recent negative press coverage had led to the Liverpool Care Pathway being used less.
  • Almost three quarters (74%) of the palliative medicine consultants surveyed held this view that negative press coverage had led to the Liverpool Care Pathway being used less.
  • Among the 321 doctors who said there was less use of the pathway, 60% (194) said patients and relatives had asked them not to use it, and 80% (258) said staff were apprehensive about relatives’ complaints.
  • Encouragingly, almost all of those surveyed (98%) did not think that pressure on beds or other resources had influenced decisions to use the pathway for end of life care. This is despite previous suggestions in the media that the Liverpool Care Pathway is used to ‘save money’ or to ‘dispatch patients because hospitals need their beds’.
  • Only 13% of doctors said hospitals should be offered financial incentives for using the pathway; 58% were against financial incentives.
  • Of the 210 doctors in non-palliative medicine specialities, 92% thought that doctors and nurses were able to judge when a person was dying. However, only 78% of the palliative medicine consultants agreed with this and felt that recognition of a dying patient and communication of this to patients and relatives was a particular training need.
  • 91% of those surveyed thought the Liverpool Care Pathway represented best practice care for the dying person. If used properly, 98% thought it allowed patients to die with dignity, with only two respondents (0.4%) disagreeing with this.
  • When asked if they would want the pathway during a terminal illness themselves, 90% of all doctors said yes and 3% said no.

The survey did raise some concern among doctors though, and principle among these was a need for extra training in the assessment and recognition of people who are coming to the end of their lives.

One trainee doctor said: “High levels of staffing are required to implement it properly. Doctors must have the time and training to communicate with families, and the proper implementation of the LCP requires highly trained nurses.”

The president of the Association for Palliative Medicine also highlighted a lack of training: “We know that there are some hospitals where the Liverpool Care Pathway is introduced, there is very little training of the staff, there is nobody who is going around making sure that it is used correctly”.

As the author of the BMJ study concludes, ‘doctors should use the opportunity to promote further education, training, and improvements in the care of dying patients.’

What concerns did doctors raise about the media coverage?

A particular concern among many doctors was about relatives’ apprehensions regarding use of the pathway, and that doctors may face complaints if patients were put on it. One palliative medicine doctor is quoted as saying “Negative press regarding LCP [the pathway] has caused additional distress for relatives at an already distressing time when their loved one is dying. This has caused a dilemma in judging if discussing the LCP will cause more distress than the benefit of being on the LCP for coordination of care in the dying phase.”

Another specialist is quoted as saying that despite concerns, people still recognise the aims of the pathway: “Often where families have been against the use of the LCP because of the negative press, they have been in agreement with application of its principles.”

Conclusion

A key issue raised by doctors in this survey was a need for extra training in assessing and recognising when people are coming to the end of their lives. Around a quarter of surveyed palliative medicine consultants felt that doctors needed more training to help them recognise that a patient was dying, and in how to communicate this to them and their relatives. As one consultant said: “There are undoubtedly cases reported in the press where end of life care has not been managed well. These should be criticisms of training, assessment and common sense. They are not correctly directed at the pathway.

“It is as irresponsible as banning insulin because of the damage and deaths that have occurred over the years due to inappropriate, inaccurate or malicious use of this drug”.

While this news is limited by the fact that it is based on an emailed survey, those who chose to respond are likely to be those with the most experience in using the pathway, its sample does represent a significant proportion of the UK experts in this field. The outcome of the reviews of the Liverpool Care Pathway are awaited, but patients, friends and family should take comfort from this news that the majority of doctors – in this survey – appear to support its use. 

 

  • 28 Comments

Readers' comments (28)

  • I can only assume that Mike Stone hasn't spotted this one yet - I'm pretty sure he will be commenting on this !

    Unsuitable or offensive? Report this comment

  • michael stone

    'with the claim that ‘fifth of doctors queasy about always telling relatives’.'

    Yes - that isn't a surprise to me.

    'Some of the coverage raised legitimate concerns, such as:

    * people may be put on the care pathway inappropriately

    * people being placed on the care pathway without discussion with the family and person themselves, if this is appropriate'

    There are legal subtleties, and legal differences, about who has to be told what, when: many doctors simply do not understand the law around these (a consultant who writes guidance for EoL, was discussing things with me a few months ago, and when I asked him 'why do you keep quoting the MCA Code of Practice at me ? The Act itself is shorter, clearer and much easier to read' he came back with 'You are unusual in finding the Act easy to read - I and most of my clinical colleagues find the Act almost impossible to understand, and we read the Code of Practice instead'. This made it impossible for me to explain why reading the Act is better, than reading the Code, if the correctness of guidance is the issue).

    Also, the LCP is not in principle a pathway, or even 'a thing' - I support a change of name to 'framework'. However, 'Care' alone, is unnecessary, uninformative and potentially misleading - but Liverpool Framework isn't very self-explanatory, and Liverpool Care-of-the-Dying Framework will, of course, get complaints that 'so it is a 'death pathway'' !

    I'm about to run out of online time - I might get back to this one, later.

    Unsuitable or offensive? Report this comment

  • Anonymous | 10-Mar-2013 1:06 pm

    How did you guess?


    DH Agent - as if ! | 10-Mar-2013 1:30 pm

    "I'm about to run out of online time - I might get back to this one, later."



    not much point in even getting started on this thread. I try to skip his comments but they are so invasive and intrusive it is really difficult having any sort of meaningful discussion with professional colleagues here.

    I only have 20 odd years of experience which includes caring for many dying patients and taking care of their families and studied medical law and ethics at MSc level where we had in-depth debate on the subject - so have nothing much to say really, except to express my despair at not being able to comment here freely.

    I have a burning issue I would like to have raised here for comment and feedback from other nurses to clarify my knowledge and understanding as the forum seems to have disappeared, but with constant interruption from MS, who seems to have far greater knowledge and experience of ow we should do our job than all of us put together, there seems very little point!

    I will probably abandon NT in favour of the RCN forums or the BMJ although I prefer the wider general professional readership of NT rather than restricting myself to RCN members only or just medics.




    Unsuitable or offensive? Report this comment

  • michael stone

    Anonymous | 10-Mar-2013 2:04 pm

    Please get a grip - your background makes you emminently qualified to join in with EoL debates:

    'I only have 20 odd years of experience which includes caring for many dying patients and taking care of their families and studied medical law and ethics at MSc level where we had in-depth debate on the subject'

    so for heaven's sake, make whatever point(s) you are interested in making, and then find out if it/they stand up to debate or not !

    3 years of trying to sort out what I see as flawed 'mindets' around some EoL issues, has made it very clear to me that:

    1) If you don't ask, you will not get engagement;

    2) If you do ask, you might get engagement, but frequently will not.

    I do not have the power, to 'silence debate' !

    I also noticed that the Forums have disappeared.

    Unsuitable or offensive? Report this comment

  • DH Agent - as if ! | 11-Mar-2013 3:11 pm

    from Anonymous | 10-Mar-2013 2:04 pm

    Does it not occur to you that nurses may not wish to debate with you and discuss your personal issues in the small space of these comments pages.

    the subject and all its different aspects is extremely complex and requires more than a brief and unelected response in this small space.

    does it occur to you that not everybody wishes to spend their Sunday or even their spare time discussing your issues with you and answering your queries and are under no obligation to do so?

    I would have thought you would have understood by now with the negative feedback and lack of that you have received that it is not necessarily lack of knowledge or inexperience which prevents people responding to you but the fact that they may have more important or better things to do with their time.

    if you want professional advice go and seek it in the appropriate places but it is not our role to provide you with a free personalised information service here on the comments.

    Maybe you would care to summarise all the comments you have made in a maximum of five lines and say what is bothering you and exactly what responses you expect from here.

    In the past I have wasted considerable time and patience trying to answer your queries but you are never satisfied with the responses you are offered and then blame it on the ignorance of those giving them or on nurses and other hc profis in general who do not wish to engage in debate with you.

    Unsuitable or offensive? Report this comment

  • Anonymous

    DH Agent - as if ! | 11-Mar-2013 3:11 pm

    one 'm' I think - eminently

    Anonymous | 10-Mar-2013 2:04 pm

    You seem to be confused. If you have got a burning issue you wish to raise and discuss, then Agent isn't stopping you from raising it. You are deciding to not post something you yourself could post, and then claiming that he is stopping you: he is not stopping you, you are choosing to not post of your own volition.

    I have looked at his stuff on the Dignity In care website, and it is obvious he is not poorly informed about these end of life issues - you might disagree with him about some things, but that is the point of discussions. And Agent very clearly knows the subject is complex - it seems to me, that is why he wants to find out what other people believe is correct.

    Unsuitable or offensive? Report this comment

  • michael stone

    Anonymous | 11-Mar-2013 3:38 pm

    You are correct about this:

    'the subject and all its different aspects is extremely complex and requires more than a brief and unelected response in this small space.'

    However, you seem to have a fundamental misunderstanding about what I'm trying to learn from NT - I'm not looking for advice, I'm trying to understand what operational nurses believe the law is, around 'MCA/Death'. Two entirely different things.

    Anonymous | 12-Mar-2013 11:46 am

    Yep, and I can't even plead a typo - I just spelt eminently incorrectly.

    Unsuitable or offensive? Report this comment


  • Anonymous | 12-Mar-2013 11:46 am

    my comment was clearly addressed to DH Agent thank you and your addition is totally irrelevant. you are clearly ignorant of the context in which my comment was made.


    DH Agent - as if ! | 12-Mar-2013 3:29 pm

    there is no misunderstanding. nurses are under no obligation to respond to you on what they believe about the law or anything else. this does not mean they are ignorant of it or do not understand it as you so often imply or even on occasion have the audacity to suggest.

    Unsuitable or offensive? Report this comment

  • michael stone

    Anonymous | 12-Mar-2013 7:03 pm

    My comment that many nurses have a very poor understanding of the MCA is not based on audacity, it is based on observation/research: it is also a view shared by quite a lot of nurses, as it happens.

    As for 'under no obligation', you are correct: but people keep telling me that the NHS is to be 'open, transparent and responsive to the public', and your approach does not fit with those objectives, in my opinion.

    Unsuitable or offensive? Report this comment

  • DH Agent - as if ! | 14-Mar-2013 3:48 pm

    Anonymous | 12-Mar-2013 7:03 pm

    I would like to see the findings and report on this research

    Unsuitable or offensive? Report this comment

Show 102050results per page

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.