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First major study of LCP finds little benefit


The controversial Liverpool Care Pathway has little clinical benefit over standard care but may improve patient dignity, the first randomised control trial of the approach has found.

The Liverpool Care Pathway Italian Cluster Trial Study Group assessed the impact of the Italian version of the end of life care programme on the quality of care of adult patients dying with cancer in 16 hospital wards across Italy.

Researchers interviewed 119 family members whose relatives were cared for on the Liverpool Care Pathway and 113 who were not.

Wards in which the pathway was used were rated slightly better than those that followed standard healthcare practice. However, researchers said it was not a significant difference.

Relatives rated the respect, dignity, and kindness shown to their family member and control of breathlessness better in wards using the Liverpool Care Pathway. There was no difference in survival times between the two approaches.

The pathway is being scrapped by the English government following controversy over its use in NHS hospitals and allegations clinicians were putting patients onto the pathway without their consent.

The authors of the study, published in The Lancet and carried out by King’s College London and the Research Institute S Maria Nuova of Reggio Emilia in Italy said the findings showed the importance of basing the pathway’s replacement on scientific evidence.

Professor Irene Higginson, co-author of the study and director of the Cicely Saunders Institute at King’s College London, said: “We must face this challenge head-on and ensure scientific evidence forms the foundations for any new initiative if end-of-life care is to be genuinely improved for patients and their families in England.”  


Readers' comments (18)

  • Yet again another proof that policies/protocols are created then scrapped because of public outcry, etc. Shouldn't we look at the practitioners' ability and understanding of these policies/protocols? Because of increase demand on workload, staffing levels, etc, there is little if not absolutely no time to send practitioners for study days/teaching sessions. LCP is a good thing. Its failure is due to practitioner's limited understanding, especially if he/she hasn't had training on it.

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  • The LCP - when used appropriately - is an excellent tool in which to manage the symptoms of those who are coming to the end of their life and was a massive improvement on what we had before.

    Unfortunately, the LCP has been used and abused in ways it was never intended. I just feel sorry for those patients who may get sub-optimal care in the interim period until LCP 2.0 comes online.

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  • adequate training, experienced clinical judgement, assessing, fulfilling and evaluating the needs of any individual patient have far greater value than any online tool which stunts any sort of cognitive function and does not enable the best quality care. following such instruments and guidelines blindly like sheep as human beings tend to do does not make up for adequate training and professional experience or lack of time and poor organisation through low staffing levels.

    human beings only have the chance to die once at the end of their lifetime and it should be made an optimal experience for them with proper and decent care by staff who only have one chance to get it right for each individual.

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  • 17/10/13 1.06pm

    I take your point, but where I work the LCP at least ensured appropriate medications were prescribed in advance to allow the nurse to appropriately care for her patient as they went on their journey. Now, patients have to wait until 'specialist' nurses involve themselves and junior doctors lack direction and experience in palliative prescribing and tend to hold off In fear of the wrath of the 'specialist' nurses who have some extremely fixed ideas. Things were much better for patients when the LCP was available to guide practice.

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  • Ellen Watters

    Researchers said it wasn't a significant difference.. Well I bet those whose dignity was improved thought it significant. Any benefit in end of life care is worth it and worth improving on.

    The study also highlighted certain limitations included lack of blinding, inclusion of all patients rather than only those with a recognized impending death for which the program would be more helpful, and unknown generalizability outside of Italy and to patients dying from other diseases.

    It also confirmed that overall control of breathlessness was rated higher with the program (54.4% versus 36.9%, P=0.026), perhaps due to more patients getting potentially appropriate medications for pulmonary secretions in the last 2 days of life.

    Surely this is a significant benefit, breathlessness is one of the most frightening symptoms at end of life.

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  • michael stone

    I'm really troubled by this one, because it is now very clear that the LCP 'failed' because it was being used by staff who 'did not get the point', or in places where clinicians were not given enough time 'to behave as if they understood the point'.

    Yes, the effectiveness of palliative treatments should be properly assessed, 100% absolutely. So that you are reasonably sure that you are OFFERING the best treatments to patients.

    But 'dying' isn't simply about the clinical process of death: patients are individuals, as are the relatives and friends of patients, and people and families, and their familial interactions, are not all the same - two patients who are in 'identical clinical situations during dying' can nevertheless still have very different personal objectives and preferences, and indeed different personal tolerances of different issues. Some patients will prefer more discomfort during dying provided they can die at home, and for others that will not be true. Some patients will prefer to be in more pain but 'alert so I can talk to my family' but others will not.

    The Independent Review of the LCP was very clear that some entirely unacceptable things were frequently happening - for example, nurses deciding to deeply sedate patients without asking for permission to do that. Etc.

    People are not tins of baked beans - dying patients are individuals, and should be treated as INDIVIDUALS and not solely on the basis of 'their clinical situation'.

    Another major problem with the LCP, is that it was developed with cancer patients whose prognoses are much easier to anticipate than the prognoses of patients with complex co-morbidities, but it had been rolled out to these more complicated clinical situations, without adequate modification.

    The LCP Review made it very clear what had gone wrong with the LCP, and their report is definitely worth reading if anybody wants to understand that:

    The LCP Review also published some other supporting literature. And, the Review Team was clearly so disturbed about what it discovered, that it wandered 'off-brief' (its 'original brief' was really to rehabilitate the LCP, after The Mail et al had been 'trashing it': in fact, the Review Team decided it was so badly tainted, it should be scrapped instead).

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  • I agree with most of the respondants as with the scrapping of the LCP immediately, we are now finding that the nurses are not assessing individually and care is much worse. Spirituality is not looked at or informing the GP as happened before and The 'care plan' is written in the medical notes and with subsequent days gets lost as the notes get written in. On call and at the weekend new people lose the plot. The multidisciplinary notation and the reassessment of symptoms does not happen and nurses are lost. Not every ward is used to care of the dying frequently and guidance is necessary. As a nursing clinician any suggestions or ideas have been rejected by the palliative care team and the higher hospital management as we are told that ' they will be organising it'. As usual the actual people caring for the patients are not being involved.

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  • If death wasn't such a taboo, the public, which includes us all, would probably be able to express their desires when such a time comes or looms. I think Michael Stone had some useful comments on looking at the wider picture and not just providing a dignified, pain-free death. I shouldn't be set in stone, we could always change our minds. The LCP was an option, not a blanket treatment.

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  • i work on an inpatient oncology ward, with massive links to the palliative care team, and we all miss the LCP.

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  • michael stone

    Anonymous | 17-Oct-2013 10:39 pm

    The LCP Review Team commented that a national conversation about dying is necessary: their review was published about a week after I had pointed out much the same thing on the BMJ 'site:

    The LCP Review team said this:

    Whatever decisions are made about the LCP (our recommendations are listed on page 52), we believe there needs to be a proper National Conversation about dying. Otherwise doctors and nurses are likely to become the whippingboys for an inadequate understanding of how we face our final days.

    I doubt that the NHS is capable of organising or creating a national conversation (as opposed to a consultation) about dying, personally - but I 100% agree about the problem !

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