Politics: The Liverpool Care Pathway and End of Life Care in the NHS

The Liverpool Care Pathway and End of Life Care in the NHS

The way in which the NHS and Hospice’s look after terminally ill patients has faced much criticism in recent months. In particular the Liverpool Care Pathway has been the main victim of the majority of this criticism being branded as “a license to kill” by the Daily Mirror and the tabloid press.

So what exactly is the Liverpool Care Pathway?

    The Liverpool Care Pathway is a framework for end of life care in the NHS. To be placed on the Liverpool Care Pathway the medical team of the dying patient, including a senior doctor, must recognise signs that a patient is close to death. If a decision is made to place the patient on the LCP, all medical treatments, which do not alleviate their suffering and are deemed no longer of benefit to the patient are withdrawn. This frequently involves the removal of I.V. drips, although patients are still encouraged to ingest food and water orally whilst on the pathway as this is considered nursing care rather than medical intervention. 

     The pathway aims to provide a form of hospice care inside a hospital environment to prevent unnecessary suffering in the patient’s final hours. It is estimated that around 130,000 patients who die in hospital per year are on the Liverpool Care Pathway, therefore making up around 29% of the total number of deaths inside hospitals each year. The medical profession’s view of the Liverpool Care Pathway is that it is an extension of one of the NHS’s key principles granting patients autonomy over their own care. However, recent failings in the use of the Care Pathway, most notably doctors failures to secure the necessary consent from patients needed to be placed on the Care Pathway warrants debate as to the appropriateness and the effectiveness of the supposed best practice and its use in the NHS.

     

Controversy

        The first major criticism of the LCP is that doctors have no objective, or 'tick box' way of determining death in a patient. As a result it seems counterintuitive to withhold a patients medication when they may have months or even years of life left ahead of them. However it is important to realise that sufferers of certain medical conditions experience similar trends in the decline of their function. Contrary to popular opinion death from cancer is relatively easy to predict due to the very sudden and rapid decline in a patients health. Similarly, the decline in a patients health from lung or cardiac failure, whilst occurring over up to 5 years also experience a fairly rapid decline with noticeable symptoms over just a few short months, although intermittent declines in health may result in some time in hospital. In contrast death from dementia or frailty is substantially more difficult to predict. For this reason patients are monitored prior to being placed onto the pathway and then monitored to an even greater extent afterwards in order to reduce the chance of an incorrect diagnosis. Patients should only be placed on the LCP when within one or two weeks of death.

       

      To be placed onto the Liverpool Care Pathway there is a moral obligation on the part of to doctors acquire the permission of the patient or of a competent family member. However, although doctors have a moral obligation to ask for permission, Marie Curie states that “the LCP is not a treatment but a framework for good practice, therefore, written consent is not required” but details that plans “SHOULD be discussed with the patient where possible and deemed appropriate and ALWAYS with the relative or carer”. However, it is estimated 65,000 patients a year are placed on the Liverpool Care Pathway without their consent being given. Such figures are shocking. However, many supporters of the LCP argue that it is not the failing of the concept behind the LCP in these matters but that of the hospital providing the care. In the words of the BMJ, in practice “the LCP can only be as effective as the clinicians who provide it”. 

    Sadly, the knock-on effect of the tabloid press’ rhetoric attacking the LCP has lead to a marked drop in the number of patients consenting to being placed on the LCP and has created a PR scandal in the NHS. This is despite evidence increasingly demonstrating that the hospice care which the LCP aims to provide, is superior to more traditional methods of end of life care. In the recent VOICES survey (the only current national survey performed) 96% of individuals experienced pain when dying. However, over 60% of patients in hospices found such pain completely relieved as opposed to only 33% in hospitals. 

    As a result of  public backlash against the LCP and following a six month independent review, the government has decided to phase out the LCP over the next 6-12 months. The LCP is to be replaced by"individualised care plans and condition specific guidance" under recommendation of the review panel. This is because although the review panel and numerous nursing and medical professional bodies acknowledge that the LCP can be used to provide a model of best practice too many patients have received poor care as a result of failings in the implementation of the Care Pathway.

-Adam