A 'Consensus Statement' has been drawn up and signed by some 20 organisations which seeks to debunk “misconceptions and often inaccurate information” about end-of-life Care Pathways such as the LCP. This follows here -
Published misconceptions and often inaccurate information about the Liverpool Care
Pathway risk detracting from the substantial benefits it can bring to people who are dying
and to their families. In response to this we are publishing this consensus statement to
provide clarity about what the Liverpool Care Pathway is - and what it is not.
The hospice movement in the UK is famous around the world for looking after dying people
with dignity and skill. Since the late 1990s, the Liverpool Care Pathway has been helping to
spread elements of the hospice model of care into other healthcare settings, such as
hospitals, care homes and people’s own homes.
The Liverpool Care Pathway:
Requires staff ensure all decisions to either continue or to stop a treatment are taken in the best interest of each patient. It is not always easy to tell whether someone is very close to death – a decision to consider using the Liverpool Care Pathway should always be made by the most senior doctor available, with help from all the other staff involved in a person’s care. It should be countersigned as soon as possible by the doctor responsible for the person’s care.
Emphasises that people should be involved in decisions about their care if possible and that carers and families should always be included in the decision-making process. Of those who responded as part of the evaluation, 94% said that they had been involved (National Care of the Dying Audit – Hospitals, MCPCIL/RCP, 2011).
Relies on staff being trained to have a thorough understanding of how to care for people who are in their last days or hours of life.
Is continually evaluated in all the places where it is in use.The Liverpool Care Pathway does not:
Replace clinical judgement and is not a treatment, but a framework for good practice.
Hasten or delay death, but ensures that the right type of care is available for people in the last days or hours of life when all of the possible reversible causes for their condition have been considered.
Preclude the use of clinically assisted nutrition or hydration - it prompts clinicians to consider whether it is needed and is in the person’s best interest. GMC guidance (2010) provides specific information regarding this issue.
In response to a question asked in the House of Lords on 20th June 2012 the Parliamentary
Under Secretary of State for Health, Earl Howe, said “The Liverpool Care Pathway has
sometimes been accused of being a way of withholding treatment, including hydration and
nutrition. That is not the case. It is used to prevent dying patients from having the distress of
receiving treatment or tests that are not beneficial and that may in fact cause harm rather
The Liverpool Care Pathway has been suggested as a model of good practice in the last
hours and days of life by successive national policy frameworks (DH, 2003 and 2006), the
national End of Life Care Strategy (DH, 2008), Quality Markers and Measures for End of Life
Care (DH, 2009), General Medical Council guidance (2010) and the NICE quality standard
for end of life care for adults (2011).
We support the appropriate use of the Liverpool Care Pathway and make clear that it is not
in any way about ending life, but rather about supporting the delivery of excellent end of life
Liverpool Care Pathway Consensus Statement - September 2012
The reality of the LCP in action is shared by a new doctor on the 'coal face' at Princess Royal Hospital. You may read his experience here -
Apologies for the delay since my last post. I was on call in a hospital that seems to confuse ‘on call’ with ‘how to avoid hiring locums’. Usually, when a junior doctor is on call, the other juniors in his or her normal team step up and get the ward jobs done. I can imagine it would be an excellent team building experience, ranking alongside mummifying the teacher in toilet roll at the end of the summer term. The folks at Princess Royal Hospital decided it would be even better for our team spirit if the only junior doctors on the medical admissions unit went on call together, leaving no one to attend the post take ward round or do the ward jobs. We had no choice but to continue with our normal jobs, whilst being responsible for clerking in every new admission to the hospital and providing cover to all the wards and of course attending all emergency calls. Our survival is an achievement worthy of an Olympic gold, and though I feel multiple human rights have been violated in the process, I am definitely a better doctor for it.
I have highlighted pertinent sections of the new doctor’s contribution to demonstrate how the LCP removes all responsibility for decision-making.
An 87 year old man is described as having co morbities. In medicine, co morbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest. A ‘likely’ terminal episode isn’t even a diagnosis.
As for being an ‘AMU’, patients are routinely shifted out of A & E into the AMU (Acute Medical Unit) as a box-ticking, ‘creative accounting’ device to reduce apparent waiting times and make everything look good on paper.
By 14.00, the drug chart written up by the consultant, the only person in the hospital who ‘knew’ this patient, had gone missing. Even so, the new doctor who ‘hadn’t even seen the patient’ was asked to re-write the medication!
The LCP recommendations are as highlighted further down in the new doctor’s account.
If the symptom is there, prescribe; if it is not, prescribe in any case! The LCP is a self-fulfilling pathway that excuses the actual responsibility of decision-making.
But the new doctor, from his account, considers his individual patient. Is the new doctor learning what Max Pemberton calls the 'art' of medicine? One hopes so. It would seem so. Then, there is hope yet.
Here is a new doctor actually taking responsibility for decision-taking, making 'assumptions' from his own clinical experience, which is all any good doctor can be expected to do.
The new doctor acted, clearly, according to what he felt were his patient's best interests. It is only to be hoped that the outcome was not already pre-determined by being placed on the Liverpool Care Pathway by the absentee consultant.
Predicting death in a time frame of three to four days, is not possible scientifically
The Liverpool Care Pathway "provides guidance on anticipatory prescribing of medications and discontinuation of inappropriate interventions." These "inappropriate interventions" will also include removal of prescribed medicines which have previously maintained the patient's stability.
Medical practice is always only an assessment of outcomes, a prognosis that continually shifts. Observation is everything and responsiveness to that observation is paramount.
Liverpool Care Pathway: The decision to withdraw treatment from a patient is an incredibly complex one
Finger on the pulse His grandfather's illness gives Max Pemberton an insight into the perils of tick-box medicine