Liverpool Care Pathway - The Dangers Of Arrogance And The Arrogance Of the Arrogant

On determining the outcome...
Seeing the glass half-empty and pouring the water back into the water jug!

A submission to the BMJ proposes that an alternative to the LCP is required for patients who might recover. This gentleman perceives the inherent dangers in the Pathway and proposes another to substitute it.

In his submission to the BMJ, the author, Martyn J Parker says that death is the inevitable outcome for those on the Liverpool Care Pathway and asks whether the use of the pathway is then appropriate for patients who may have a chance of recovery.

The author further notes that the CQUIN targets have permitted and encouraged this inappropriate use of the LCP. Those severely ill with a high risk of dying, but for whom death is not inevitable, will have been placed on a terminal care pathway.

Admitting an inappropriate use has consequences. It is to admit to the manslaughter of 100s, 1000s of patients.

Death is the inevitable outcome for those on the Liverpool care pathway, so is the use of this pathway appropriate for patients who may have a chance of recovery, asks Martyn J Parker Having a pathway for all situations is an obsession of today’s medicine. Sometimes this has led to a pathway that was designed for one situation being adapted or used in another—and not always to good effect. This seems to be what has happened with the Liverpool care pathway. It was designed to help those providing care for terminally ill patients who are in their last days of life. The pathway is now being used for patients who may be in their last days or weeks of life but for whom there remains a chance of recovery. Is this appropriate?

The author proposes an alternative pathway for such patients with high risk of dying but for whom death is not certain.

There are two responses in the BMJ  to this submission by Martyn J Parker.

These propose that the LCP is adequate as it stands because the guidelines make provision to review the patient every four hours and that there are, in any case, already alternate pathways, such as the Amber Care Pathway.

However -

Furthermore, life is not black and white. Only a foolish or naive clinician would claim 100% certainty in predicting when a patient was "unquestionably within the last days" of life. We must therefore be able to make balanced clinical assessments regarding our patients' realistic chance of recovery. The LCP should be used when that assessment points towards a diagnosis of 'dying', not a diagnosis of 'deteriorating'. Although there will always be exceptions to the rule, if we genuinely believe there is a reasonable chance of recovery then we should not be considering the LCP in the first place. I believe this is the point that Mr Parker is trying to make but it is our responsibility as clinicians to understand the basic principles and philosophy of the LCP so that we don't suggest inappropriate plans of care for our patients.

On a side note, it is true that the LCP is not appropriate for all patients who may be approaching the end of life but many Trusts are now introducing 'Amber Care Bundles' or similar pathways which can be used when a patient's overall condition is deteriorating over time yet death is not thought to be imminent. Mr Parker may want to look into whether his Trust has a similar system in place or in development.

In regard to four-hourly review, however, it is pertinent to refer back to remarks on The Big Question -

Dr. Philip Howard –

I think one of the problems with the Liverpool Care Pathway is it’s predicated on a false premise, namely that you can accurately diagnose death; you can make an accurate prognosis as to when that person is going to die, within the next few hours or days. And there’s no scientific evidence that we can do that. And I know of no calibration tools that we can use to say just how accurately we can make that prognosis. That’s the danger. Now, if you then sedate the patient, stop observations, stop interventions, and stop food and fluids, the patient must die. Whether or not they would have died anyway, they must die if you adopt that regime in full. 

Nicky Campbell – 

Is it the case… Is it under constant review when somebody’s on the Pathway?

Dr. Philip Howard –

One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.

Pause.

The unanswered question:

Dr. Philip Howard –

One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.

The focus of medicine and those who practice it has been subtly subverted. After 2000 years, the Hippocratic Oath is denied respect and cast aside.

The focus of the healer is no longer to heal the sick but to first determine whether they should be healed!

The function of the healer was always to plunge into the deep to attempt a rescue. The focus was always to try, however futile the circumstance.

It is a dangerous perspective which classifies the patient as being beyond aid and launches them forth upon a Pathway. Any Pathway! It is precisely that perspective which has promoted the attitude, recently described as 'callous', that when you're dead you're dead. 

It is the arrogance of the arrogant. Lacking in all humility are they who propose that treatment is determined not by the nature of the ailment but by a determination that their patient is dying. To make such an assumption already predetermines the outcome.