Liverpool Care Pathway for the Dying Patient

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The Liverpool Care Pathway for the Dying Patient (LCP) is a UK care pathway (excluding Wales) covering palliative care options for patients in the final days or hours of life. It was developed to help doctors and nurses provide quality end-of-life care.

The Liverpool Care Pathway was developed by Royal Liverpool University Hospital and Liverpool's Marie Curie Hospice in the late 1990s for the care of terminally ill cancer patients. Since then the scope of the LCP has been extended to include all patients deemed dying.

While initial reception was positive, it was heavily criticised in the media in 2009 and 2012.

In 2012, it was revealed that just over half of the total of NHS trusts had received or were due to receive financial rewards to hit targets associated with the use of the care pathway.[1] These payments are made under a system known as “Commissioning for Quality and Innovation” (CQUIN), with local NHS commissioners paying trusts for meeting targets to “reward excellence” in care.[1]

In July 2013, the Department of Health released a statement which stated the use of the LCP should be "phased out over the next 6-12 months and replaced with an individual approach to end of life care for each patient".[2]

Aims[edit]

The pathway was developed to aid members of a multi-disciplinary team in matters relating to continuing medical treatment, discontinuation of treatment and comfort measures during the last days and hours of a patient's life. The Liverpool Care Pathway is organized into sections ensuring that evaluation and care is continuous and consistent.

It was not intended to replace the skill and expertise of health professionals.

In the first stage of the pathway a multi-professional team caring for the patient is supposed to agree that all reversible causes for the patient's conditions have been considered and that the patient is in fact 'dying'. The assessment then makes suggestions for what palliative care options to consider and whether non-essential treatments and medications should be discontinued.[3]

In practice, the implementation of this guideline was found to be lacking. Many decisions are taken in ward settings without the oversight of an experienced doctor of medicine. In almost half of the cases neither patients nor family were informed or consulted that it was decided to place the patient on the LCP.[4]

The programme suggests the provision of treatments to manage pain, agitation, respiratory tract secretions, nausea and vomiting, or shortness of breath (dyspnoea) that the patient may experience.[5]

The care was not designed to be a one-way street to death. However in 2012 controversy arose indicating that in most cases it was, and even patients that might have survived longer otherwise died because of the LCP.[6] In a response to negative media reports, Clare Henry and Professor Mike Richards issued a statement on behalf of the NHS End of Life Care Team, claiming that the pathway was reversible, and stating that'approximately 3% of patients initially put on the pathway are removed from the pathway when reassessed' - although no source was cited for this figure.[7]

Assessment[edit]

Initial assessments of the effects and value of the pathway were largely positive. A 2003 study published in the International Journal of Palliative Nursing found that nurses saw the pathway as having a generally positive effect on patients and their families.[8] A 2006 study published in the same journal found that, despite some "initial skepticism", the doctors and nurses who were interviewed saw the approach as having a valuable place in hospice care, though its use on 'dying' patients on general wards was not addressed.[9] A multi-centre study was published in 2008 in the Journal of Palliative Medicine that found that nurses and relatives thought that the approach improved the management of patients' symptoms, but did not significantly improve communication.[10] The authors concluded that they "consider LCP use beneficial for the care for dying patients and their family."[10]

A 2009 study published in Journal of Pain and Symptom Management studied the impact of the pathway on the end-of-life care of over three hundred patients and found that it produced a large decrease in the use of medication that might shorten life and increased patients' involvement in their medication and care.[11] A 2009 survey of 42 carers providing the pathway was published in the Journal of Palliative Medicine, it found that 84% were "highly satisfied" with the approach and that it enhanced patient dignity, symptom management and communication with families.[12]

Research into its use outside the UK Healthcare System have not, however, demonstrated the same results: a cluster phase II trial conducted in Italy showed no statistically significant improvement in patient's symptom control.[13] On the other hand, the study did find significant improvements in the other four dimensions it surveyed: respect, kindness and dignity; family emotional support; family self-efficacy; and coordination of care.[13]

Jonathan Potter, the director of the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians stated in 2009 that their audits showed that "where the Liverpool Care Pathway for the dying patient (LCP) is used, people are receiving high quality clinical care in the last hours and days of life".[14] The 2009 audit looked at end-of-life care in 155 hospitals, and examined the records of about 4,000 patients. A major criticism of this study was that each of the participating hospitals was only asked to submit datasets from 30 patients: arguably, the study was heavily biased by the ability to 'cherry-pick' the most favourable datasets, and the lack of availability of all data for independent scrutiny and objective assessment.

Version 12 of the LCP was launched on 8 December 2009, after over two years of consultation. Amongst other revisions, it includes new decision-making support on whether or not to start the LCP; highlighted guidance to review the appropriateness of continuing on the pathway at any time if concern is expressed by either the patient, a relative, or a team member; and new prompts to support decisions on artificial nutrition and hydration.[15][16] An editorial in the BMJ judged the new release did "much to tackle recent criticisms".[17]

Results of independent review[edit]

In July 2013, the results of an independent review into the LCP led by Baroness Julia Neuberger were published.[18] Accepting the review's recommendations, the government advised that NHS hospitals should phase out the use of the LCP over the next 6–12 months, and that "NHS England should work with CCGs to bring about an immediate end to local financial incentives for hospitals to promote a certain type of care for dying patients, including the LCP.[2]

Controversy[edit]

Medical issues[edit]

Commenting on the new sedation-and-dehydration regimes[clarification needed], in 2008 Jacqueline Laing, a legal academic at London Metropolitan University, warned that "[i]n the context of changing positive law, however, it is important to understand the considerable financial, scientific and medical interests there are in controlling death. These interests need not be illicit in themselves. The interests of hospital and state efficiency, freedom from unnecessary compensation claims, scientific research and increased supplies of organs for transplant are not in themselves wrongful. When understood in the context of law that invites bureaucratised homicide and serious mutilation of the non-consenting or ill-informed vulnerable, these interests introduce new extrinsic concerns."[19][20]

A 2008 article in the American Journal of Hospice and Palliative Care criticised the Liverpool Pathway for its traditional approach and not taking an explicit position on the artificial hydration for critically ill patients.[21] A 2009 editorial in the Journal of Clinical Nursing welcomed the impetus towards providing improved care at the end of life and the more widespread use of integrated care pathways, but warned that much more research is needed to assess which of the several approaches that are in use is most effective.[22]

In 2009 The Daily Telegraph wrote that the pathway has been blamed by some doctors for hastening the death of some mortally ill patients, and possibly masking signs that the patient is improving.[23] This story was criticised by the Association for Palliative Medicine and the anti-euthanasia charity Care Not Killing as inaccurate.[3][24] In contrast, The Times welcomed the pathway as an attempt to address patients' wishes and warned about "alarmist" press coverage of the scheme.[25][26]

Media reports[edit]

The LCP has continued to be controversial. Many witnesses have testified that elderly patients were admitted to hospital for emergency treatment and put on the LCP without documented proof that the patient consented to it, or could not recover from their health problem; 48 year old Norfolk man Andrew Flanagan was revived by his family and went home for a further five weeks after doctors put him on the LCP.[27] The Royal College of Physicians found that up to half of families were not informed of clinicians’ decision to put a relative on the pathway.[28]

Writing in the Daily Mail, Patrick Pullicino has claimed that doctors' use of the LCP protocol has turned it into the equivalent of euthanasia of the elderly.[29] In a letter to The Daily Telegraph, six doctors belonging to the Medical Ethics Alliance[28] called on LCP to provide evidence that the pathway is "safe and effective, or even required", arguing that, in the elderly, natural death is more often painless, provision of fluids is the main way of easing thirst, and "no one should be deprived of consciousness except for the gravest reason."[6]

Financial inducements to NHS trusts[edit]

Under figures gained from a 2012 freedom of information request by The Daily Telegraph, 85 per cent of NHS trusts were revealed to have adopted the Liverpool Care Pathway. Just over half of the total of NHS trusts have received or are due to receive financial rewards for doing so. At many hospitals more than 50 per cent of all patients who died had been placed on the pathway and in one case the proportion of foreseeable deaths on the pathway was almost nine out of 10.[1]

According to responses from a sample of 72 trusts, at least £12.4 million had been paid out in the two to three years to 2012 to trusts which hit targets associated with use of the care pathway. Overall 61 of NHS trusts which responded to the survey said that they used the pathway, translating to 85 per cent of the total. Of those, 62 per cent disclosed that they had either received, or expect to receive, cash rewards for meeting targets associated with the implementation of the pathway. The remainder said they had adopted the LCP without receiving any payments.[1]

Under a system known as “Commissioning for Quality and Innovation” (CQUIN), local NHS commissioners pay trusts for meeting targets to “reward excellence” in care. Targets vary from area to area but in some cases trusts are given specific targets to ensure that a set number of people who die in their hospital are on the LCP.[1] In response to the survey, a handful of trusts openly spoke of either hitting or missing targets connected to the LCP in their responses.[1]

The Central Manchester University Hospitals NHS Foundation Trust - which received £81,000 in 2010 for meeting targets relating to the LCP - said the proportion of patients whose deaths were expected and had been placed on the pathway more than doubled to 87.7% from 2011 to 2012. The Bradford teaching Hospitals trust, which qualified for CQUIN payments of more than £490,000 from 2010 to 2012, saw the number of patients dying on the pathway more than double to 51 per cent from 2009 to 2012.[1]

See also[edit]

References[edit]

  1. ^ a b c d e f g John Bingham, NHS millions for controversial care pathway, The Telegraph, November 1, 2012
  2. ^ a b Press release Overhaul of End of Life Care system - Department of Health, 15 July 2013
  3. ^ a b The Liverpool Care Pathway The Association for Palliative Medicine of Great Britain and Ireland
  4. ^ Donnelly, Laura (1 December 2012). "Half of those on Liverpool Care Pathway never told". The Daily Telegraph (London). 
  5. ^ Care for the dying patient Marie Curie Palliative Care Institute Liverpool Care Pathway for the Dying Patient (LCP)
  6. ^ a b Millard P, Cole A, Bearcroft R, Craig G, Hill D & Knowles M (8 July 2012). "Deadly one-way street". The Daily Telegraph (London). Retrieved 10 July 2012. 
  7. ^ Liverpool Care Pathway: response to media reporting, NHS National End-of-life care programme, 15 October 2009
  8. ^ Jack BA, Gambles M, Murphy D, Ellershaw JE (September 2003). "Nurses' perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting". Int J Palliat Nurs 9 (9): 375–81. PMID 14593273. 
  9. ^ Gambles M, Stirzaker S, Jack BA, Ellershaw JE (September 2006). "The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions". Int J Palliat Nurs 12 (9): 414–21. PMID 17077800. 
  10. ^ a b Veerbeek L, van Zuylen L, Swart SJ, et al. (March 2008). "The effect of the Liverpool Care Pathway for the dying: a multi-centre study". Palliat Med 22 (2): 145–51. doi:10.1177/0269216307087164. PMID 18372379. 
  11. ^ van der Heide A, Veerbeek L, Swart S, van der Rijt C, van der Maas PJ, van Zuylen L (November 2009). "End-of-Life Decision Making for Cancer Patients in Different Clinical Settings and the Impact of the LCP". J Pain Symptom Manage 39 (1): 33–43. doi:10.1016/j.jpainsymman.2009.05.018. PMID 19892509. 
  12. ^ Mullick A, Beynon T, Colvin M, et al. (September 2009). "Liverpool care pathway carers survey". Palliat Med 23 (6): 571–2. doi:10.1177/0269216309106459. PMID 19460832. 
  13. ^ a b M. Costantini et al (2013), The Liverpool Care Pathway for cancer patients dying in hospital medical wards: A before–after cluster phase II trial of outcomes reported by family members, Palliative Medicine, forthcoming doi:10.1177/0269216313487569
  14. ^ National care of the dying audit 2009 Royal College of Physicians 14 Sep 2009
  15. ^ LCP Generic Document, version 12, and supporting documentation, December 2009
  16. ^ John Ellershaw and Deborah Murphy, LCP Statement, 13 October 2009
  17. ^ Edmonds P, Burman R, Prentice W (2009). "End of life care in the acute hospital setting". BMJ 339: b5048. doi:10.1136/bmj.b5048. PMID 19952043. 
  18. ^ Independent report: Review of Liverpool Care Pathway for dying patients - Department of Health, 15 July 2013
  19. ^ Laing, Jacqueline “Food and Fluids: Human Law, Human Rights and Human Interests” in Artificial Nutrition and Hydration C. Tollefsen, ed., Springer Press 2008, pp. 77-100
  20. ^ See also on the legal regime surrounding the LCP see Laing, Jacqueline (2002), “Vegetative” State – The Untold Story” New Law Journal 152, 1272; (2004), “Mental Capacity Bill - A threat to the vulnerable” New Law Journal 154, 1165. (2004), “Disabled Need Our Protection” Law Society Gazette 101, 12. (2005), “The Mental Capacity Bill 2004: Human Rights Concerns” Family Law Journal 35, 137-143.
  21. ^ Craig G (2008). "Palliative care in overdrive: patients in danger". Am J Hosp Palliat Care 25 (2): 155–60. doi:10.1177/1049909107312596. PMID 18445867. 
  22. ^ Ingleton C, Gott M, Kirk S (April 2009). "The beginning of the end (of life care strategy)". J Clin Nurs 18 (7): 935–7. doi:10.1111/j.1365-2702.2008.02616.x. PMID 19284430. 
  23. ^ Kate Devlin, Sentenced to death on the NHS, Daily Telegraph, 2 September 2009
  24. ^ Liverpool Care Pathway Care Not Killing 15 September 2009
  25. ^ Joan Bakewell The Liverpool Care Pathway brings the subject of dying into the open The Times September 14, 2009
  26. ^ David Rose The palliative care nurse: some days I wish I worked in a shoe shop The Times September 14, 2009
  27. ^ Stevens, John (12 October 2012). "A pathway to euthanasia? Family revive father doctors ruled wasn't worth saving". Daily Mail (London). Retrieved 14 October 2012. 
  28. ^ a b Adams, Stephen (8 July 2012). "Hospitals 'letting patients die to save money'". The Daily Telegraph (London). Retrieved 24 July 2012. 
  29. ^ Doughty, Steve (19 June 2012 Updated 31 August 2012). "Top doctor's chilling claim: The NHS kills off 130,000 elderly patients every year". Daily Mail (London). Retrieved 14 October 2012. 

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