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Liz Bryan: ‘The Liverpool Care Pathway failed because it oversimplified care of the dying’


End-of-life care is an art and adequate training is needed to deliver it, says Liz Bryan

I often hear it said – by those who can do it – that delivering adequate care to those approaching the end of life is not rocket science. I tend to agree but it is, nevertheless, an art. This is perhaps why the Liverpool Care Pathway has apparently failed in its purpose.

The LCP aimed to support health professionals unaccustomed to caring for the dying to manage the transition of the final stages of people’s lives through to death. However, it has oversimplified a process that requires a specific practical wisdom that is not necessarily present in all those who find themselves at the bedside of the dying.


‘Specialist practitioners thought that perhaps one way of transferring the model of care developed in hospices into hospital practice was by designing a step-by-step guide. There is absolutely nothing wrong with the guide but clearly it is not that simple to transfer the “art”’

When reflecting with students on the limitations of the LCP, I have used the analogy of the pilot of a light aircraft.

The plane seemed almost like an extension of himself. He was able to loop the loop and dive and even, if the fuel cut out for any reason, right the plane and safely land it with some degree of confidence.

Those who watched on the ground admired his skill and asked him to show them how to do the same. Because it seemed so easy to him, he thought all he needed to do was write down the instructions in “easy” steps for them to follow.

The novice pilots took the planes up into the air and, as long as all went smoothly, were able to land – but very few were able to get the plane out of difficulty and many crashed. The pilot had underestimated his tacit knowledge acquired over time and through experience.

In this way, specialist practitioners thought that perhaps one way of transferring the model of care developed in hospices into hospital practice was by designing a step-by-step guide. There is absolutely nothing wrong with the guide but clearly it is not that simple to transfer the “art”.

In 1978, Carper spoke of the “fundamental ways of knowing” in nursing; these are not only empirical (that is, factual knowledge that can be empirically verified) but personal (the ability to imagine oneself in a situation), ethical (awareness of moral questions and choices) and aesthetic (being able to relate to the uniqueness of a given situation in its wholeness). She presented this typology as a tool for generating clearer, more complete thinking, and for learning about experiences. It led to a reaction in nursing against overemphasing knowledge that was solely empirically derived – so-called “scientific nursing”.

By emphasising that attitudes and actions that are perhaps more personal and more intuitive are also centrally important, the concept of “reflective practice” in nursing was further developed. This principle is of even greater significance when the learning is associated with an area of practice as potentially emotive and complex as caring for the dying.

Through an end-of-life care educational initiative designed to be delivered by hospices to nurses working in acute settings, the value of role-modelling and providing a safe and supportive learning environment in which to reflect and make sense of experience has yet again been proven. The Quality End of Life Care for All programme acknowledges the need for professionals to be shown how to provide care for those who are approaching the end of life and their families. These professionals then need to be accompanied as they try out their new learning and develop skills appropriate to the setting in which they work.

Hospices – there are 220 hospice inpatient units in the UK – are almost exclusively third sector and are only able to provide specialist care to approximately 7% of the population. They are a valuable educational resource and, as yet, largely unrecognised and certainly underutilised.

QELCA invites acute hospitals to release teams of clinical nurse managers from the same department or clinical directorate to spend one week in small groups on placement at their local hospice.

Specially trained hospice nurse trainers then facilitate a combination of ward experience and in-depth reflection. The same facilitators then provide ongoing support in collaboration with hospital specialist teams over the following six months.

Piloted so far with more than 20 hospitals, the evidence suggests that this mode of education delivery does change attitudes and empowers practitioners to change not only their own practice but also to lead change for their teams and within their organisations (See

Liz Bryan is lecturer practitioner in palliative care at King’s College London’s Florence Nightingale School of Nursing and Midwifery and St Christopher’s Hospice


Carper B (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science ;1: 1, 13-24.


Readers' comments (68)

  • Excellent article and analogy. Keep up the good work Liz & Co.

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  • quick reflection - will read article and hopefully more comments in detail later but I think we need to be very careful about mechanising and protocolising many aspects of healthcare, which the LCP appears to do if not fully understood and reflected on, and especially at the end of life.

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  • talk about stating the obvious! As a member of my local end of life forum I have been to many many workshops, training sessions etc around the LCP and in every single one the necessity for underpinning training and knowledge to support staff in the correct use of the LCP has been highlighted. Without that, yes, it becomes yet another tick box exercise.

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  • Anonymous | 13-Aug-2013 4:50 pm

    it clearly is not obvious to everybody otherwise there would be no issue. as you say, training is neccessary which appears inadequate or lacking in some places.

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  • "QELCA invites acute hospitals to release teams of clinical nurse managers from the same department or clinical directorate to spend one week in small groups on placement at their local hospice."

    Why? They almost exclusively have nothing to do with the delivery of patient care. Send the nurses who actually carry out the care! But look at the other issues surrounding end of life care, like lack of staffing and availability of clinical support. Stop expecting nurses to do the impossible with nothing.

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  • Thank you Liz

    The real question to ask is whether "end of life care" can ever be successfully provided within the context of a busy acute ward environment !

    My own belief is that provision of dedicated hospices should be expanded and fully funded by the NHS -------

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  • Very good article. Thank you.
    I agree with Jenny above.
    Having worked in hospice care, with a grounded emphasis in end of life care and most recently in a busy acute ward. There is no realistic translation when using the LCP.
    An alternative is required, but it should be tailored to the environment. A generic form/pathway designed to deal with the complex needs of irrevocably dying patients cannot be tick-boxed in or out of vogue.
    I sincerely hope that an experienced, practicing and progressive nurse takes a lead in creating the new pathway/guidelines/strategy, etc.

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  • tinkerbell

    I agree with Jenny and above anonymous. I do not have much experience with LCP but it is not hard to imagine that a busy medical ward may struggle to provide the specialism and time that is needed.

    It is only right that those who have the specialist knowledge and experience be heard and listened to on this one so that we get it right, otherwise all talk of dignity of care without the proper environment and staffing to provide that care, once again, becomes rhetoric.

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  • care of dying patients used to be an integral part of nursing training and many were very good at it.

    although acute wards do not provide the optimal environment for this type of care it is inevitable and often without being left any choice that some patients will die there and it is up to nurses to do their very best as they have always done but it requires time to provide this unrushed type of care for the patient and their family. obviously this depends upon, like all nursing care, enough staff. it maybe that training also needs to be re-examined to ensure it is adequate to cope with the changes in this environment.

    If the LCP is to be continued successfully or any further instrument or new methods and developments are introduced then obviously additonal comprehensive training in their use is essential and it should go without saying that clear, open, transparent and honest communications are vital with all concerned and involved in their care at every stage of the care in response to each patient's changing condition and the needs of their families and the team supporting and caring for them.

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  • michael stone

    The LCP seems to have mainly failed for 2 reasons.

    1) The LCP tried to describe an 'approach/mindset' for EoLC, but inadequate staff expertise in acute settings often led to the LCP being seen as ' a set of instructions';

    2) Nurses and doctors in hospices, usually have significantly more time to spend with individual patients and their families, than nurses and doctors in acute settings: 'time with, and listening to, the patient/family' is crucial if EoLC is going to 'work okay' - even if you do 'understand it all' you couldn't 'do it right' without enough 'time'.

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