Liverpool Care Pathway for the Dying Patient
The Liverpool Care Pathway for the Dying Patient (LCP) was 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. Now discredited, the LCP was widely abused as a 'tick box exercise', with patients being casually assessed as terminal, heavily sedated, and denied water so the diagnosis became self-fulfilling. Hospitals were also provided cash incentives to achieve targets for the number of patients dying on the LCP.
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. The LCP was then extended to include all patients deemed dying.
While initial reception was positive, it was heavily criticised in the media in 2009 and 2012. 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". However, The Telegraph reported that the program was just rebranded and that its supposed replacement would "perpetuate many of its worst practices, allowing patients to suffer days of dehydration, or to be sedated, leaving them unable to even ask for food or drink."
A leading critic, Professor Patrick Pullicino, stated that the new proposals from the National Institute of Health and Care Excellence were ‘totally wrong and very misleading’ on the crucial issue of patient hydration. "Overall they’re quite similar to the Liverpool Care Pathway, they still have the problem of diagnosis but in addition, in terms of hydration, the language is very ambiguous. There is even a part there that says that withholding artificial nutrition does not hasten death. It’s definitely going to."
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 organised 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.
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.
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. 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.
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. A 2006 study published in the same journal found that, despite some "initial scepticism", 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. 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. The authors concluded that they "consider LCP use beneficial for the care for dying patients and their family."
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. 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.
Research into its use outside the UK Healthcare System has not, however, demonstrated the same results: a cluster phase II trial conducted in Italy showed no statistically significant improvement in patients' symptom control. 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.
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". 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 more than two years of consultation. Among 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. An editorial in the BMJ judged the new release did "much to tackle recent criticisms".
Results of independent review
In July 2013, the results of an independent review into the LCP led by Baroness Julia Neuberger were published. 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.
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. 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.
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. This story was criticised by the Association for Palliative Medicine and the anti-euthanasia charity Care Not Killing as inaccurate. In contrast, The Times welcomed the pathway as an attempt to address patients' wishes and warned about "alarmist" press coverage of the scheme. A German study in 2015 found no indication of hastening death. In fact, one in ten patients improves and leaves the pathway.
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. 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.
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. In a letter to The Daily Telegraph, six doctors belonging to the Medical Ethics Alliance 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."
Financial inducements to NHS trusts
In October 2012 figures released under the Freedom of Information Act showed that some two thirds of NHS trusts had received incentive payments for meeting "targets" for using the LCP, and that such payments totalled £12 million or more.
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