Wednesday, 3 October 2012

Liverpool Care Pathway – Debunked!

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 
than good.” 

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 -

On Call Week: Liverpool Care Pathway, STAT

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.

There were many learning experiences I want to share. Perhaps the most poignant one was writing up the Liverpool Care Pathway for an 87 year old man with multiple co morbidities and a likely terminal episode of pneumonia. I saw the consultant write up the drug chart in A&E in a matter of minutes at around 0930. By 1400, the patient was an AMU and the drug chart had gone missing. The patient had hours to live at best and my consultant, who was the only person in the hospital who knew this patient, was in a meeting. I hadn’t even seen the patient when I was asked to re-write his LCP medication.
My stream of consciousness went something like this: What dose of morphine should we use? I don’t know if he is opiate naive…does it matter at this stage? Can an F1 write big doses of morphine up? Oh, he’s on oxygen. Does that have to stop? It’s symptom relief only…but does the oxygen make him feel less breathless? Maybe we could monitor his sats and see if he needs it…but hold on, is that invasive monitoring? He looks dry, and I’m pretty sure the LCP says that actually you can use artificial hydration, I remember a case study on the GMC website. How can I tell if he is agitated, or in pain? Do the family decide…
As ever, when in doubt with a prescription, I speak to a pharmacist. These are the most amazing people in the hospital. They are fountains of knowledge raining on the gasping fish out of water that is the F1 asked to make a decision about which drug to use.
“Hi. I need help.”
“What is it?”
“I’ve been asked to prescribe the LCP to a terminally ill patient. How do I write up a syringe driver? How do I decide the rate and dose? How do I…”
She produced a LCP booklet that was about 30 pages long. I started reading from the front, which felt like opening a new TV and reading the company propaganda from Sony when it’s pretty clear that the things I really need are going to be later in the booklet. I never understand why companies insist on selling you the product in the first few pages after you have clearly just bought it.
I skipped forward to the prescribing section. There were five pharmaceutical targets to the care:
1. No pain
2. No vomiting/nausea
3. No agitation/restlessness
4. No respiratory distress
5. No respiratory secretions
The management of each of these depended on whether or not the patient was already experiencing the symptom. If the patient had the symptom, an appropriate drug should be written up as a syringe driver with a PRN subcut breakthrough dose. If the patient were not yet experiencing this symptom, then a PRN dose should be prescribed. As I began attempting to fill in the prescription chart, I realised I could not write anything unless I knew what the particular needs of my patient were. I decided to see the patient.
The patient was a tall man who had clearly lost weight recently. Folds of skin hung loosely off bones that are not meant to be so easily visible. He was breathing rapidly but with shallow breaths, with each inspiration accompanied by what sounded like basal crepitations but amplified and coming out the mouth. He did not seem to be in pain, but how do you tell in a patient who is not verbalising or even vocalising? He was as peaceful as he could be with all the secretions in his respiratory tract, and his respiratory rate was around 16.
I asked the nurse looking after him what she thought about his symptom control over the last few hours. I also spoke with his daughters to work out what symptoms (if any) were bothering him most in the last few days.
For pain, we looked through the notes, including his previous prescriptions, and there was no suggestion of any pain nor any history of painkillers above PRN paracetamol. I decided to use PRN diamorphine 10mg s/c for pain control based on   the LCP recommendation.
The patient had not been vomiting or expressed any nausea. PRN haloperidol 1mg s/c was the medication of choice for this scenario. As the patient appeared to be opiate naive, and 10mg diamorphine is a pretty big first dose of opiate, there was a significant risk of inducing vomiting in his last few moments alive, which needed antiemetic cover.
The advantage of haloperidol was that is was also useful for agitation and restlessness. The patient had none of that at the moment, so a PRN dose was all that was needed. The other option recommended was midazolam, which would be more sedating. As his daughters were around and presumably wanted to speak with him, I preferred the less sedating option.
I have since learnt that respiratory distress is often tied to anxiety in the dying patient, and both should be treated together. Relaxation exercises and physiotherapy, as well as basic treatment like sitting the patient up if tolerated, can be helpful. Medically, morphine can be used PRN. There was no need to write up any additional medication in this case. We decided that oxygen was not needed, as the mask was probably uncomfortable and as the respiratory rate did not increase with the oxygen off, the patient probably was not in respiratory distress. I realise that I am making the assumption that respiratory rate and respiratory distress have the usual relationship that they have in non palliative medicine. If anyone has anything to add on this I would be really grateful.
Finally, the respiratory secretions. The patient had symptoms, so needed hyoscine hydrobromide. I gave this as a subcut syringe driver over 24 hours, with a PRN top up as needed.
I didn’t have long before I was back to my usual on call routine of pretending to be in 3 places at once. But just for a few minutes, I felt like a doctor who was independent from the chaos in the rest of the hospital. I was making the care of my patient my one and only priority, and it was rewarding.

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
Professor Pullicino
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

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