Thursday, 22 November 2012

Liverpool Care Pathway – Straight From the Horse's Mouth

The Liverpool Care Pathway -

Its frailties are accepted and admitted.

Doubts gnaw; reservations give cause to reconsider.

Second thoughts second guess...

This is the BMJ -

The assault on the Liverpool care pathway

LCP - an evidence free zone                                        11 November 2012

Mcartney gives a balanced report of the media coverage of the lcp. More than 20 organisations have backed the lcp(1).
However, doctors should wake up and smell the coffee. We are not infallible - and the press reports, although admittedly one sided and perhaps exaggerated, do have a message. Doctors can and do get it wrong. We have witnessed young and inexperienced doctors start the lcp when elderly patients are admitted with a stroke or pneumonia rather early on in the illness ie within the first few hours or days, before giving nature or reversible treatment a chance. Liam Farrell's anecdote of his early experience of prognostication and the possible use of the lcp, likely to be tongue in cheek, did generate a lol response (2).
At the end of the day, we must readily acknowledge that doctors are human - and will err on over treatment or under treatment. Admittedly, predicting end of life is an inexact science fraught with room for significant error, illustrated by cases highlighted in the media.It is right for the press to raise these issues - serving as a check on "doctor knows best", ensuring we critically evaluate our practice. Expediting the 2013 round of the national audit (3) might help to reassure, but the media coverage has made many of us circumspect about the use of the lcp - a good thing or bad?
When in doubt, should we rely on the various groups endorsing the lcp or ebm? The majority of doctors may not be aware that , regrettably the lcp is not backed by the gold standard of evidence of an rct. Perhaps the climate is right for an rct of the lcp vs usual care. A similar study has been started in Italy (4).
1)Kmietowicz Z. Doctors’ leaders, charities, and hospices back Liverpool Care Pathway. BMJ2012;345:e6654.
2)farrell bmj 2012;345:e7355
3)Kmietowicz bmj2012;345:e7511
4)Costantini et al; The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial.BMC Health Services Research 2011, 11:13 doi:10.1186/1472-6963-11-13

Domnik Felix D'Costa, consultant physician
royal wolverhampton hospitals, wv10 0qp
Competing interests: None declared

Randomized controlled trial

From Wikipedia, the free encyclopedia
randomized controlled trial (RCT) (or randomized comparative trial) is a specific type of scientific experiment, and the gold standard for a clinical trial. RCT are often used to test the efficacy of various types of intervention within a patient population. RCT may also provide an opportunity to gather useful information about adverse effects, such as drug reactions.

1 comment:

  1. Massimo Costantini, I've been reading that name all over the place...

    Why do so many of these, by now, familiar, names of palliative care researchers crop up together time and again, Eldoel? And so often in the same context?