Liverpool Care Pathway – A Design For Death

This is not a dole queue; it is a death queue...

A Design for Death 

 Knowledge gives us power

Aber arbeit macht frei 

Just the silence of the Lamb; an eternal peace, not dignity  

No good taking to the bottle

That won't take away the hurt and the scars

That show from where we came

They don't talk about life, They raise the spectre of death

No kiss it better, repair or mend

As we are told that this is the end

A design for death

A design for death

A design for death

A design for death

[Paraphrased from: "A Design for Life" - Manic Street Preachers]

Once the mindset is set on this path, The Pathway is the only outcome.

"People are ‘approaching the end of life’ when they are likely to die within the next 12 months." 

The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’? 

This 'challenge' question is not new. The St. Mungo workers have been 'challenging' themselves for some time! Now, it has wormed its way into the surgery. 

Watch out, you old-uns, next time you're sat opposite the quack and he seems to be looking at you strangely, sizing you up perhaps, it might be for benefit of the undertaker! 

This is from the GSF Prognostic Indicator Guidance - 

The GSF Prognostic Indicator Guidance 
The National GSF Centre’s guidance for clinicians to support earlier recognition of patients nearing the end of life

Why is it important to identify people nearing the end of life?

‘Earlier identification of people nearing the end of their life and inclusion on the register leads to earlier planning and better co-ordinated care’

(GSF National Primary Care Snapshot Audit 2010 )

About 1% of the population die each year. Although some deaths are unexpected, many more in fact can be predicted. This is inherently difficult, but if we were better able to predict people in the final year of life, whatever their diagnosis, and include them on a register, there is good evidence that they are more likely to receive well-co-ordinated, high quality care.

This updated fourth edition of the GSF Prognostic Indicator Guidance, supported by the RCGP, aims to help GPs, clinicians and other professionals in earlier identification of those adult patients nearing the end of their life who may need additional support. Once identified, they can be placed on a register such as the GP’s QOF / GSF palliative care, hospital flagging system or locality register. This in turn can trigger specific support, such clarifying their particular needs, offering advance care planning discussions prevention of crises admissions and pro-active support to ensure they ‘live well until they die’.

Definition of End of Life Care
General Medical Council, UK 2010
People are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:
 Advanced, progressive, incurable conditions
 General frailty and co-existing conditions that mean they are expected to die within 12 months
 Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
 Life-threatening acute conditions caused by sudden catastrophic events.


The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’?

The same flow chart formula is employed -

“Using the GSF ‘PIG’ has helped us to identify these patients earlier than we previously did, especially those with non-cancer, thereby giving them earlier support as they face the end of their lives, leading to fewer crises and hospital admissions.” (GP using Next Stage GSF Training Programme ‘Going for Gold’)


‘It is recommended that people approaching the end of life are identified in a timely way.’
(Draft Recommendation NICE Guidance in End of Life Care 2001)


“For many people suffering from a chronic illness, a point is reached where it is clear that the person will die from their condition. Despite this, for many conditions it may be difficult, if not impossible and potentially unhelpful, to estimate prognosis accurately. The Prognostic Indicator Guidance developed as part of the Gold Standards Framework (GSF) provides useful prompts or triggers to a healthcare professional that discussions about the end of life should be initiated, if this has not already happened”. (DH End of Life care Strategy 2008 England)

Development of this guidance paper. This guidance was originally commissioned from the GSF Centre in June 2006 to support GPs include appropriate patients on their QOF Palliative Care Registers i.e. those considered to be in the final 12 months of life. It is regularly revised following extensive consultation with clinical and disease specialist groups, palliative care specialists and GPs in the Royal College of General Practitioners. Particular thanks go to the NHS End of Life Care Programme and University of Edinburgh team for their help. Since publication, this Guidance has been widely used by clinicians in many sectors in the UK and internationally. A list of detailed references is available on request. This is one of several tools available to support improvements in End of Life Care, and further details on best use, IT support and further developments can be obtained from the GSF Centre.

The Gold Standards Framework Centre CIC info@gsfcentre.co.uk www.goldstandardsframework.org.uk 

The document concludes - "This guidance was originally commissioned from the GSF Centre in June 2006 to support GPs include appropriate patients on their QOF." 

Well, that explains a lot; that pre-dates by a year my mother's untimely demise at the hands of LCP nurses on the Pathway of which we were kept in blithe ignorance!