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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.

Amanda Cheesley is long-term conditions adviser at the Royal College of Nursing

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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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