Liverpool Care Pathway - The Case To Answer

Woolly-brained or woolly-headed, under-lying this review is the same scatter-brained thinking that produced the LCP.



A Trial hosted on a US dot Gov website is going ahead and is currently recruiting. Yes, 'recruiting'.

So, we asked...

Where are they going with this? When the review is published next week, perhaps, we might be able to make better sense of it...

The Review

Fact:

• The Liverpool Care Pathway (LCP) has never been properly tested.
• The LCP has never been subjected to a proper randomised clinical trial.

This is admitted to and confirmed here:

1.21 The rapid evidence review commissioned for the Review concluded that there is no strong evidence on potential benefits or on potential adverse effects and risks of ‘pathways’ for managing the dying phase in end of life care. No research has yet produced evidence by robustly comparing these pathways with other forms of care.

Recommendation 9 of the Review states -

The National Institute for Health Research should fund research on improving, where possible, the accuracy of prognostic tools for the last weeks to days of life. This would cover, for example, the accuracy of prognostication where that is possible, suitably configured, mixed method trials of different forms of care during dying, specific interventions, such as hydration and nutrition, and symptom control measures. 

So, that's where they are going with this. The worrying thing is just who are they 'recruiting'? Perhaps more worrying, they are accepting healthy 'volunteers'. Persons afflicted of mind but not of body...?

They don't have the same compunction in Flanders' killing wards.

Of course, of course. Mr. Hunt, a man obsessed or a man inspired...?

There is one odd thing. If it is worthy of note, I am not sure, but I shall note it. The paragraph references at right follow consecutively. The recommendations at left do not. Eleven follows nine and precedes ten. Both ten and eleven relate to research into and a review of training.

The question of adequate and proper training is also mentioned here:

1.22 There appear to the Review panel to be other significant gaps in evidence about the LCP. These include:
• The extent to which staff who decide upon and implement the ‘pathways’ in various settings, including acute hospitals, are competent to care for the dying, let alone to a sufficiently high standard.
• Evidence of which factors (such as training, on-going expert support, or the environment) result in good or poor implementation of the LCP and its underpinning principles.
• More information on incidence, features, trajectory and consequences of placing people on the LCP who then recover in that particular care episode.
1.23 Formal, independent, prospective testing of the LCP has not yet been carried out after nearly 10 years of its dissemination, which is a major cause for concern. The National Care of the Dying Audit – Hospitals (NCADH)24 does provide some limited evaluation of the LCP.

Now, this is a case to answer that Dr. Bee Wee, amongst others, must be summoned to the witness box to answer to! People have died on this Pathway. Lives have been taken on this Pathway. And that is murder for people have been placed on this pathway who were not dying.

And that is another case to answer!

It is admitted there are no precise ways of diagnosing dying. In fact, it is not scientifically possible.

The Review

There, they admit it. But...

And the woolly-thinking of the woolly-brained here stands out:

1.11 The Review panel recommends that NHS England should work speedily to issue clear definitions of time frames relating to end of life decision-making, and that these definitions be embedded firmly into the context of existing policies and programmes so that there is no room for doubt.

Good evidence is provided for there not to be a Pathway or Plan or call it what you will...

Given the difficulty of predicting when a patient is actually going to die, placing patients on the LCP can lead to considerable upset in families expecting the patient to die sooner than they do or, if they recover, understanding what has happened. Families expect that, because a patient is placed on the LCP, they must be in the last hours or days of life; but the Review panel knows from the evidence it received that some patients then remain on the pathway for several days or longer. Relatives naturally become distressed, and this is heightened if pain relief is not effective, and ‘normal’ drugs, nutrition and, particularly, hydration are discontinued. Doctors and nurses need to communicate with patients and relatives or carers far more honestly about the difficulties in diagnosing the dying phase, admitting to, and being explicit about uncertainty and dealing in likelihoods, not certainties. The need for good communication at all times in end of life care is an issue that arose time and time again during this Review, and it is addressed elsewhere in this report.

It is not addressed. The Review constantly revisits and reviews itself.

1.31 The LCP document makes clear that the process of diagnosing dying includes a multidisciplinary team (MDT) assessment. It rightly reminds the team that it should seek the advice and support of the specialist palliative care team when there are areas of difficulty or doubt, and states that ‘once the clinical decision is taken, ‘patient, relative or carer communication is focused on recognition & understanding that the patient is dying.'

Alternative EoLC pathways are mentioned:

1.12 The LCP is not the only approach to care for people in the dying phase, but is one of a range of integrated care approaches for end of life. There are a number of locally or nationally developed end of life integrated care approaches developed according to these principles and covering the different timespans of end of life. Notable among them are the Gold Standards Framework, the Amber Care Bundle, and the All Wales Integrated Care Priorities for the Last Days of Life. The LCP is one version of these generic approaches, distinct in being concerned specifically with the last days and hours of life. Local variations of the LCP and other approaches are based on its principles. Common to all of these approaches is that they must first be agreed by a multidisciplinary team, regardless of setting.

These are all still up and running. As mentioned in these pages, the Welsh Collaborative Care Pathway, for instance, had a 'fundamental rewrite' and was relaunched because of 'adverse publicity'. Now, the same is happening to the LCP? These should not be looked to to replace the LCP; rather, they should be subjected to scrutiny and review themselves.

It is further recommended:

More use of evidence based prognostic tools and education and training in them is needed.

This is the GSF Prognostic Indicator Guidance –

It was Dr. Barton's claim that she could look at someone and tell that they were dying.

This quote is in the Review. They are all quite, quite arrogant:

And this is the SPICT –

SPICT is a trademark of the University of Edinburgh and NHS Lothian but it was not found to be registered at the Intellectual Property Office.

The SPICT^TM  is sometimes used in combination with the "Surprise Question":
Would you be surprised if this patient died within 12 months? [See the GSF Prognostic Guide]

The Review points out that:

1.30 The reports of incomplete and wrongly completed forms that the Review received are of grave concern, reminding the Review panel of a key finding of the Mid Staffordshire Public Inquiry – insufficient openness, transparency and candour.
The Review Panel strongly supports Robert Francis QC’s call for a duty of candour, and recommends that clinicians be reminded by their registration bodies that the deliberate falsification of any document or clinical record, in order to deflect future criticism of a failure of care, is contrary to GMC28 and NMC guidelines and therefore a disciplinary matter.

It is to be hoped that we will see movement in this matter both on the part of the regulatory bodies and in bringing these culprits to justice in a court of law.