Liverpool Care Pathway – Painting Over The Cracks

Here is IJCP (International Journal of Care pathways) -

Welsh Collaborative Care Pathway Project; 10 years experience of implementing and maintaining a care pathway for the last days of life

1. R Johnstone⇓, 
2. A Jones and 
3. A Fowell

+Author Affiliations

1. Department of Palliative Care, Betsi Cadwaladr University Health Board, Bodfan, Eryri Hospital, Caernarfon, UK

1. Correspondence: Rosalynde Patricia Johnstone, Department of Palliative Care, Bodfan Eryri Hospital, Caernarfon LL552YE, UK (Fax: 01286 662792; Email:rosalynde.johnstone@wales.nhs.uk)

Abstract

This paper describes the progression over 10 years of a project to implement a care pathway for the last days of life across Wales, leading to a major revision of the pathway in 2010. An initial 38 sites throughout Wales representing hospital, hospice and community settings registered. This has led to a robust end of life care network across the principality. In 2007 an annual audit cycle was established, with outcomes being fed back to the participating sites as well as informing an annual review of the integrated care pathway (ICP). In 2010, there are now over 100 sites using the ICP to deliver high-quality end of life care to patients in Wales. There has been a drop in the number of recorded variances of symptom problems. As a result of widespread adverse publicity, a fundamental re-write of the pathway was carried out. The new pathway was launched at a national conference and all teams provided with new documentation and explanation for the need to change. Within three months, most teams were using the new ICP and individual visits were carried out to those that had difficulty. In conclusion, it is possible to implement, sustain and maintain the use of an ICP for the past days of life over a large and varied geographical area. Major changes can be implemented quickly if sufficient involvement and explanation are carried out. The lessons learnt are transferable to other disciplines seeking to use an ICP.

• Accepted February 24, 2011.

• © The Royal Society of Medicine Press

As a result of "widespread adverse publicity, a fundamental rewrite of the pathway was carried out." Really...?

"There has been a drop in the number of recorded variances of symptom problems. As a result of widespread adverse publicity, a fundamental re-write of the pathway was carried out. The new pathway was launched at a national conference and all teams provided with new documentation and explanation for the need to change. "

We are talking here about the the placing of a living human being on a program of  protocols that is going to end their life. What 'adverse publicity' would that be that forced a 'fundamental rewrite'? A medical protocol should be grounded in and  founded on the hard facts and disciplines of medical science, not subject to and amended at whim by way of a reaction to some 'adverse publicity' reported anecdotally. Meanwhile, the actual anecdotal evidence mounting up goes mostly unreported and ignored.

Is it that there is no hard and fast 'science' involved, perhaps? After all -

"We know that prognosis is not accurate and we often get our predictions of prognosis wrong. A tool based upon prognosis is therefore dangerous as it may become a decision that a person will die. " ((Dr Philip Howard)

And nothing is ever a foregone conclusion. We are not Gods: we cannot tell with certainty, but must work with the situation and the individual.

"Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically." (Professor Pullicino)

And from the CARE2 LCP Petition site -

23:40, Dec 02, Dr. Patrick Pullicino, United Kingdom
It is not scientifically possible to diagnose impending death as the LCP purports to do. The LCP is instead an assessment of the perceived quality of life of the patient by the medical team and as such is euthanasia.

Giving the ship a fresh coat of paint will not disguise its purpose nor remove its flaws!

A 'robust' implementation of the protocols must also ensure a conformity of outcomes and 'a drop in the number of recorded variances of symptom problems.' Patients are being treated as falling into a category rather than as individuals.

This is MAX PEMBERTON in The Telegraph:

No pill or potion is a

match for compassion

I have often seen this happen; patients you are convinced will follow a clear, definable illness-trajectory prove you wrong. It's this unpredictability that makes medicine so fascinating; the fact that the body has a remarkable capacity to confound expectations. Even for those with a terminal illness, there can be no certainties. It's for this reason that I despair of the Government's new treatment pattern for palliative care. The "Liverpool Care Pathway" involves a series of tick-box assessments, which aim to assess the likelihood of death in patients deemed to be terminally ill in hospitals, nursing and residential homes.