Liverpool Care Pathway - The Report

A medical holocaust has proceeded and Ellershaw laughs.
Ellershaw laughs...




There are RTAs (Road Traffic Accidents) and there are PTAs...

No, that's not Parent Teacher Associations, that's Pathway Traffic Accidents. Only, these aren't accidents; this is deliberate; this is murder. And Ellershaw laughs.

This is The Report on BBC Radio 4 –

BBC Radio 4

Thursday 15 August 2013

The Liverpool Care Pathway

Critics dubbed the controversial Liverpool Care Pathway the 'road to death' and accused the NHS of killing off thousands of elderly patients. Supporters say it has helped terminally ill people have a peaceful and dignified death. The campaign against the Liverpool Care Pathway was fuelled by countless stories in the newspapers of patients being deprived of food and water and heavily sedated.

Following the publication in July 2013 of an independent review, the government announced that the Liverpool Care Pathway will be phased out in NHS hospitals in England. But some medical professionals fear the baby has been thrown out with the bathwater.

In this programme, Helen Grady looks at the back story - how and why the Liverpool Care Pathway was rolled out, the opposition campaign and the likely impact for patients of the Pathway's demise. She talks to relatives of patients who were on the pathway, doctors and palliative care experts.

Transcript -

For the past few years, hospital patients who are dying have tended to be managed by staff following a controversial system called the Liverpool care pathway. In this weeks edition of The Report, now, Helen Grady investigates why the government has decided to scrap its use in English NHS hospitals...

"My mum had a very peaceful passing... And, clearly, it can be used to make sure that people can die with dignity and that their families are given time and space to, you know, to come to terms with what's going on." - Sam Long

Helen Grady - For many people, the Liverpool Care Pathway provided what we all want when a loved one is dying - a good end. But that wasn't the case in every hospital where it was used.

"Nan didn't want to die. You know, it wouldn't have even been euthanasia. She... she didn't want to die. So, as far as we were concerned, it would have felt to us like our nan had been starved to death. And killed." - Kathleen Vine's granddaughter 

Helen Grady - So was the Liverpool Care Pathway to blame for experiences like this? Or was the LCP, as it also known, just a scapegoat for wider problems in the NHS?

"The LCP tries to dumb down end of life care and I think trying to make end of life care simple by a tick box approach is doomed to failure."

"If it is implemented properly with the right education, you're getting best practice for care of the dying."

Helen Grady - In this program, we'll find out how the Liverpool care Pathway became so widely used. And the role that pro-life campaigners have played in its demise. And we'll meet a woman whose family insisted doctors stop using the LCP and is still alive four months after they were told to plan her funeral.

"If it hadn't a been for my family, I wouldn't be sitting here talking to you now. I was on the way out and I would have been just another statistic." - Kathleen Vine

Helen Grady - The NHS is full of jargon. And doctors and nurses love a good acronym. Which may be why the LCP is hardly ever given its full name - The Liverpool Care Pathway for the Dying Patient. Even when the full name is used, a lot of patients find it confusing. Some thought it meant they were being moved to Liverpool. So, what exactly is the Liverpool Care Pathway?

Pathways are used all over the NHS. Basically, they're sets of guidelines that prompt doctors and nurses to use the best tests and treatments. for a patient's condition. The Liverpool care Pathway is designed to kick in when a patient is in the final hours or days of their life.

And it was badly needed says Irene Higginson, Professor of Palliative Care at King's College, London:

"The problem that the Liverpool Care Pathway was trying to fix was most people do, in fact, die in hospital and it was well known that it wasn't of good quality. It was one of the most frequent complaints to the Health Ombudsman and families were particularly concerned about poor communications. When I was a junior doctor, there would be some instances when, actually, the consultant wouldn't visit the people who were dying; he just wouldn't see them. They didn't quite know what to do or what to say. Or how to talk about it. And so this left people distressed." - Irene Higginson

"Mum loved her music, absolutely loved it. And one of the things we asked the nursing staff was if we could play some music. They were fine with that because, apparently, hearing is one of the last senses to go. She responded to, you know, to the music and to one of her favourite tracks. And she just had a little tear in the corner of her eye." - Sam Long

Helen Grady - It's now four months since Sam Long's 69 year-old mother, Rhoda, died at the Royal Berkshire Hospital in Reading. She was admitted after suffering a brain haemorrhage that left her unconscious and unlikely to survive according to specialists from two different hospitals:

"If my mum, as the woman that she was, had died before we got to hospital, and my observation of mum over those three days was that she was dying on a cellular level. If that was the inevitable outcome, then people should be able to have the choice, the families have the choice, that people can pass pain free and with dignity and with compassion for their loved ones." - Sam Long

Helen Grady - Mrs. Long is grateful the hospital where her mother died was using the LCP. But other families have had less positive experiences. There have been stories of patients sucking water from a sponge after fluids were withdrawn. But how is the Liverpool Care pathway supposed to work? How better to find out than the place where it was created - Liverpool - and from one of its creators?

"So once we start care with the pathway, there are a number of things that we do at that initial assessment. The key to that is communication with the relatives as we need to explain to them that we think things have deteriorated, that there is a change in the patient's condition and that we now feel that they are in that dying phase." - John Ellershaw

Helen Grady - John Ellershaw is professor of palliative medicine at the Marie Curie Palliative Care Institute in Liverpool.

"You can see here where the symptom control and care is achieved. If it's not been achieved, it's recorded there as a variant. Whether additional medication or additional advice or support is being given to the family." - John Ellershaw

Helen Grady - Today, the LCP is used in more than 200 NHS Hospitals in England, Scotland and Northern Ireland. And in more than 20 other countries. It was developed in the earl 1990s when specialists from Marie Curie were working in the charity's Liverpool hospice and in the city's Royal Hospital.

"Twenty minutes away, in our hospice, when people are going through that dying phase, that area of care was done very welll. We had the right programme for the patient, we had communication with the family, and if you get that part of the process of care right, then the patient can have the right symptom control and the relatives can have the right level of psychological....support in that environment. So, the idea was could we not translate what we see in the hospice 20 minutes away into this chaotic dying process that we had in hospitals? So that's when we sat down and we spent six months developing the first integrated care pathway for the dying patient." - John Ellershaw

Helen Grady - But the LCP isn't the only way of caring for dying patients. Wales, for example, has its own pathway. So, how did the LCP become so widely used over the past 12 years in the resy of the UK? Sam Ahmedzai is professor of palliative medicine at the University of Sheffield:

"The Liverpool Care Pathway came to prominence about the time when the Department of Health, or specifically the Cancer Action team, was setting up its end of life care strategy. As part of that end of life care strategy, the Cancer Action team obviously need some headline projects to show the way. And I think what happened was they seized upon the Liverpool Care Pathway which was just being set up about then and said, well, why don't we make this one of our frontline projects. What, I think, went slightly wrong here was that it seemed such a good idea to take what hospices do and apply them in other settings that, I think, that everybody said let's, let's just apply it; let's rush this across the whole country and make sure that everybody is doing the same thing. And, once you've got the Department of Health behind you, then it's an unstoppable machine." - Sam Ahmedzai

_______________________________________________________

Helen Grady - The Department of Health describes the LCP as an evidence-based framework. That suggests it's been vigorously evaluated and shown to benefit patients. But is that really what happened with the LCP? Professor of Palliative Care and Director of the Cicely Saunders Institute, Irene Higginson:

Irene Higginson - The evidence review that's from the University of Nottingham shows that the evidence about the Liverpool Care Pathway is fairly weak. It doesn't show you what's happening in another group of people who are not getting that treatment or change or intervention. And we normally try and measure that sort of change in something called a randomised control trial where half the people get the new treatment and half the people don't.. That's, for example, how most drugs are assessed.

Helen Grady - Is that usual practice, that a scheme would be rolled out across the NHS without that type of trial?

Irene Higginson -  I don't think it's wise to roll out something to that level without, at least, without a randomised trial or something close to it. Unfortunately, I think that things are sometimes roled out across healthcare without necessarily that level of evidence generation. And that's because people want to do something and they see something that intrinsically makes sense and so they think, oh, this is a good idea, let's do this, I don't think it will cause any harm.

Helen Grady - So it looks like a solution, let's roll it out...

Irene Higginson - Yeah...

Helen Grady - There's another, more alarming, theory as to why the LCP became so popular with hospital trusts. Some were offered financial incentives to use it, with part of their budget held back if they failed to meet training targets or if the number of patients using the pathway was too low. For those whose relatives had been LCPed, as some were starting to put it, the newspaper headlines make grim reading:

• Hospitals bribed to put patients on Pathway to Death
• Hospitals paid millions to put patients on Death Pathway

Helen Grady - The story created a media storm that left doctors and nurses feeling under siege and families worried that their loved ones had been bumped off for profit. It was a picture that medical staff didn't recognise and Professor John Ellershaw, one of the creators of the LCP, says the incentive scheme was misrepresented.

John Ellershaw - Well, I think linking financial incentives to dying patients has not been helpful. When these financial incentives were put in place, the reasoning behind it was that it would help more people who were dying to be supported by the LCP.

Helen Grady - But it was perceived as encouraging clinical staff to write patients off. That's how it was seen, wasn't it?

John Ellershaw - Well, that's how it was reported.

Helen Grady - The doctors and nurses I've spoken to all said that the targets had little or no impact on frontline staff. But they were under pressure to use the pathway and were often unaware of the targets. But the link between dying patients and financial incentives, coupled with the weak evidence that the pathway worked, made it hard to defend against a growing litany of bad experiences, many involving elderly patients.

Kathleen Vine - All I can remember is they weren't feeding me. Up above my bed, they'd put 'Nil by Mouth' and I was begging for food.

Helen Grady - Can you remember when you were asking for food what happened? How did the hospital respond?

Kathleen Vine - They were ignoring me...

Helen Grady - They just ignored you...

Kathleen Vine - Yeah. And I was being left to die! And they told my family that I was dying. If it hadn't a been for my family, darling, I would be dead now, I wouldn't be talking to anyone. I don't know, I'd be up there or down there, I don't know". I had too many boyfriends, I could've been down there.

Helen Grady - [Laughs] Four months after doctors using the LCP decided she was dying Kathleen Vine is back at home and in good spirits. Mrs. Vine was admitted to hospital with a dislocated shoulder. She developed pneumonia but was never diagnosed with a terminal illness. Her grandaughters, Helen Bishop and Alison English, say the Liverpool Care Pathway was used to justify sedating Mrs. Vine and denying her food and water.

"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely - and he came in and he was sort of asking us if we'd thought about the funeral and how we were going to tell our daughters, and just, sort of, getting us to talk about it, I suppose. And I was saying, I just can't believe it. You know, she came in with a dislocated shoulder ; we're now being  told she's dying. Nanny woke up at that point. And she had a full on conversation with him. She actually flirted with him. You know, she was saying, ooh, aren't you lovely? You've got lovely eyes. Surely, that's not a dying person. She's chatting you up, asking if you'll feed her... This, this can't be right, you know. [Laugh...] - Kathleen Vine's granddaughters

Helen Grady - What did he say, then, when she started chatting him up? Did he realise you possibly weren't dying?

Kathleen Vine - Yeah, he realised that alright.

"We all completely agree with the Liverpool Care Pathway for terminally ill people and we understand that that can be a much less intrusive way to spend your final hours. Our problem was that we felt that the medicine she needed was being withheld, the food she needed to get better and get stronger was being withheld. Nan didn't want to die. It would have felt to us like our nan had been starved to death and killed." - Kathleen Vine's granddaughters

_______________________________________________________

Helen Grady - The hospital told The Report that when a decision is taken to start using the Liverpool Care Pathway, a patient is closely monitored and reviewed and that using the pathway doesn't mean that  food and water are withheld. But there were many cases like mrs. Vines' and, in January, as more and more of these made it into the news, the Department of Health launched an independent review of the LCP. It found that the pathway was regularly used as a reason to deny patients food and water. The LCP's creator, Professor John Ellershaw, says that should never have happened.

John Ellershaw - You should be encouraging patients to take food as appropriate and/ or hydration as appropriate. And, alongside that, if the patient is unable to take oral hydration, you should consider whether artificial fluids are appropriate. And that's in line with General Medical Council guidance.

Helen Grady - So, why then did the review panel hear so many stories about patients begging for water and being told by doctors or nursing staff, no, you can't have it?

John Ellershaw - If healthcare professionals are telling relatives or patients that they can't have hydration, whether oral or artificial, because the LCP says they can't, then, they're not meeting the guidance or interpreting it correctly, because it doesn't say that.

Professor Sam Ahmedzai - I've got a copy of the Liverpool care pathway in front of me and I can see that the statements it makes about hydration are all very negative.

Helen Grady - Professor Sam Ahmedzai.

Professor Sam Ahmedzai - It doesn't say you mustn't use clinically assisted hydration, such as drips, but it makes it very clear that it doesn't believe they're much good. And it makes it very clear that it believes that it's more natural to die without any kind of assisted hydration. And there is good evidence from other areas of research that suggests that people who are dehydrated can become confused, agitated and, perversely, the response to that confusion and agitation for some people who are being treated by the Liverpool Care Pathway would be to start sedation. So their patients were dehydrated, became agitated, sedation was started, it was then in a downward spiral.

Helen Grady - Previous versions of the LCP were even less clear about hydration than the current 12th version. And we've been told that many hospitals are still using an older version. What's more, recent NHS figures show that only 29% of hospitals using the LCP provide mandatory training. Usually, when a new scheme is rolled out in the NHS, there are regular checks to make sure it's being used properly. In this case, the checks were carried out by the Marie Curie Palliative Care Institute, the creators of the LCP. I asked its director, John Ellershaw, why their audit didn't spot the problems:

John Ellershaw - We know that, from the National Care of the Dying Audit...

Helen Grady - Which you carried out.

John Ellershaw - Which is stated in there by the institute here, supported by the Royal college of Physicians, that over 80,000 people who have been supported with the LCP in our hospitals in England, I think the vast majority of those patients appear well supported and have died dignified deaths. Sometimes people have been through a very distressing in that dying phase that, no matter what we would do and whatever interventions we make, it will always be distressing.

Helen Grady - But Professor Sam Ahmedzai says the LCP audits were flawed.

Professor Sam Ahmedzai - The audits were not about the outcome; they were not about whether the dying was better for those patients, but it was all about were forms filled in, were certain things done? now, so that's very much about what we call the processes, not about the outcomes. So, I'm not very impressed by the audits that have so far taken place.

_______________________________________________________

Helen Grady - Problems for the LCP first came to the public's attention back in 2009 when a group of doctors wrote to the Daily Telegraph with a stark warning -

If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death.

Helen Grady - Professor Sam Ahmedzai remembers that first letter and the others that followed it.

Professor Sam Ahmedzai - Sometimes it would be a doctor that had a particular case they wanted to, sort of, sound off about, but also pressure groups from some religious groups who felt that the pathway was a kind of euthanasia pathway, a death pathway, and these were exactly the kind of headlines which came out in the media. I'm pretty sure that the Liverpool care pathway is not used as a form of back-door euthanasia, but that's how it was portrayed by some of the media.

Helen Grady - And why did the media portray the LCP as a form of euthanasia? Because that's how a number of doctors had started to describe it. Among them was Professor Patrick Pullicino, a neurologist who wrote of his concerns to a member of the House of Lords. This was forwarded to Simon Caldwell, a freelance journalist who saw the beginning of a story that would run and run

Simon Caldwell - That submission was sent to me and I thought it was explosive. Shortly after, I was told by my contacts at the Medical Ethics alliance where they were meeting in London at the Royal Society of Medicine and they were being addressed by Patrick Pullicino. If he comes and says that publicly, then, I thought this would be an opportunity to write about the LCP. And he gave a very, very strong presentation in which he said all those things again, and more besides.

Helen Grady - Top doctor's chilling claim: The NHS kills off a hundred and thirty thousand elderly patients every year. The Daily Mail ran Simon Caldwell's report. The figure in their headline may be debatable but the story put the LCP on the public and the political agenda and marked the beginning of a growing panic about its use. Patrick Pullicino's concerns about the LCP stem from his work as a neurologist in Kent, caring for stroke patients. As a doctor and as a Catholic, he has both practical and ethical objections to the pathway

Patrick Pullicino - Essentially, it uses a prediction that somebody is going to imminently going to die instead of solid clinical criteria that are of use in other hospital pathways. Once you do label a patient as dying, then that patient is treated in a different way.

Helen Grady - But there are people who say it does provide a dignified death, a peaceful death, and they really value that.

Patrick Pullicino - I think our idea of dignity of putting someone peacefully to sleep is wrong and it's changed our view of management of death. and it's said that many people don't start to live until they know that they are going to die. They may make categorical changes in the way they relate to God, in the way they relate to, you know, estranged family members. The actual pathway and the treatment, potentially, takes all that away from somebody. And i think that, particularly for Christians and believers in God, that is something that is very serious.

Helen Grady - You're talking about a need for people to be conscious at that moment, as some people see it, of meeting their maker.

Patrick Pullicino - Yes, exactly. if you've got a chance to make a change that you want to make that is important, for example, a spiritual change, then you have to be given time and you have to be given support to do that. And it's not good enough just to say, have you had a chance to speak to your pastor and then tick that box and carry on with the treatment."
Helen Grady - It's a religious argument, that's an argument coming from a pro-life perspective really, isn't it?

Patrick Pullicino - Yes, yes it is, yeah.

Helen Grady - Some of the fiercest critics of the Liverpool Care Pathway do come from a pro-life perspective. They've been some of the most vocal in bringing problems to the public attention. Why do you think that is?

Patrick Pullicino - Possibly, a sensitivity that might be part of the issue. There may be people who look at death in a different way to the standard way of looking at death. Though that might have been why the objections came from this particular area, but thank God they did.

Helen Grady - Professor Pullicino is keen to stress his religious objections to the LCP come second to his practical objections as a scientist. But Catholics have played a significant role in the LCP's demise. The journalist  Simon Caldwell, is also a media consultant for the Catholic Church. As well as reporting Professor Patrick Pullicino's claims, he used the Freedom of Information Act to reveal how hospitals were being offered financial incentives to use the LCP. I asked him how many of the stories raising concerns about the LCP had been written by him.

Simon Caldwell - Quit a lot [laughs] The Daily Mail, The Daily Telegraph and The Sunday Times. They didn't always go under my name which is common practice. but once the families became involved, they were ringing the national newspapers directly and they were being picked up by the journalists there.

Helen Grady - It seems that some of the people who were the first to raise concerns about the Liverpool Care Pathway were Catholic doctors. How important a part do you think they have played in bringing this to the public's attention?

Simon Caldwell -  I wouldn't suggest that this a Catholic cause by any means. Em, I'm a Catholic ,and quite openly so. I interviewed two doctors in the course of last year. One was Catholic, one was Jewish. But I'm also aware that there is a senior palliative care doctor who has been very critical of the LCP as euthanasia . If I was to offer a reason why Catholics seem to be involved, I would tell you that it is the teaching of the Church is that you don't kill. Well, I mean, I don't think that's exclusive to Catholics and I think that anybody who follows a conscience will reach the same conclusion whatever persuasion they are.

Helen Grady - Once the alarm had been sounded, news rooms were flooded with calls from bereaved families. For Professor Sam Ahmedzai. it was their often harrowing stories that triggered the independent review into the LCP.

Professor Sam Ahmedzai - It started off in one or two newspapers  like The Daily Telegraph, The Daily Mail, and then other media grabbed it. I've got a lot of records from the BBC grabbing stories like this. It got to a point where the media were really in a bit of a frenzy about it and I think that's when the Department of Health had to pay attention."

Helen Grady - The Department of Health has backed the review's most urgent recommendation - that the Liverpool Care Pathway be phased out in England over the next six to twelve months. For Kathleen Vine, it's the right decision. Her family forced doctors to stop using the pathway and to start feeding her and giving her water. But she says others on her ward were not so lucky.

Kathleen Vine - And when I think about it, there's a lot of patients didn't have anyone to visit them. and I think, you know, what they must've done, they've not fed them and no-one's there to take over like I had. I've been very, very lucky. I don't feel like dying at all. I've got my lipstick on every morning, I do my hair, I make sure I look nice.

Helen Grady - No, you look in very fine form.

Kathleen Vine - Thankyou, thankyou very much.

Helen Grady - But for people like Sam Long there are serious concerns about what will replace the LCP. Since her mother's death, she's talked to her father about the kind of care he'd like when he's in his dying days.

"He was saying, right, if it comes to that in my place, I want to go on the Liverpool Care Pathway, like your mum. Can't dad. It's, you know, it's not being offered. Well he was stunned. So, I think it's actually a great shame. i certainly don't think it should be dismissed out of hand. i think it needs reviewing and rigorous monitoring. Yeah." - Sam Long

Helen Grady - Many of the experts that I spoke to for this programme said that, in the right hands, the Liverpool Care Pathway can deliver the best care for dying people. By rolling it out so widely, it's created to turn the LCP into a brand. Their motives were good - to share best practice. But neither they nor the Department of Health did enough to protect the LCP brand and, as a result, it's become toxic, in England at least. Professor John Ellershaw:

John Ellershaw - I think, in retrospect, to have had an accreditation process linked with the programme may have reduced the poor implementation in some care settings. However, if you do that, there's a cost and a high cost sometimes for organisations there may be a barrier in implementation as well as a lever 

Helen Grady - So less hospitals might have used it if they'd had to pay.

John Ellershaw - I think so and we've worked with the LCP, not just in England, but in over 20 countries in the world. We have translations into six languages. And it's recognised internationally as the best care for the dying patient.

Helen Grady - Have they done it better in other countries? Have they been tougher about training and monitoring?

John Ellershaw - I think they are more systematic in their implementation and methodologies than other healthcare systems

Helen Grady - Than here?

John Ellershaw - Laughs [Public schoolboy stifled snigger, snort, snort!]

Helen Grady - The NHS in England has less than a year to work out what will replace the LCP. There's talk of a more individualised approach but it's hard to see how that will work without a serious investment in training, staff, and one key thing that's so far been lacking according to Professor Irene Higginson of the Cicely Saunders Institute:

Irene Higginson - One of my biggest hopes is that going forward there's going to be a proper evidenced based approach.

Helen Grady - But that's going to take years, isn't it?

Irene Higginson - There isn't a quick fix solution to this problem

Helen Grady - It is going to take time, but maybe it's better  to take time and do it right than roll it out and then find that it all has to be checked and reviewed and changed.

_______________________________________________________

From The Report -

"For the past few years, hospital patients who are dying have tended to be managed by staff following a controversial system called the Liverpool care pathway."

The Liverpool Care Pathway has, for the past few years, been used to manage patients 'diagnosed' as dying but not necessarily 'dying'. The LCP has not only been misused; it has been misapplied. The former is misadventure or manslaughter. The latter is murder.

"In this program, we'll find out how the Liverpool care Pathway became so widely used. And the role that pro-life campaigners have played in its demise."

To be fair to Denise, reports had been surfacing for years and the self-obsessed, omnipotent DoH had just looked the other way in the thought or the hope that the issue would just go away. They had the great EoLC programme umbrella raised and run by the NCPC beneath which to shelter. It was, after all, just a bunch of 'religious nuts' who were raising issue and making a fuss...

They weren't much moved by the angry shouts and distressed voices coming out of Gosport. The report into the Barton Care Pathway was still being held back, earmarked to be used as toilet paper...

It was Denise Charlesworth-Smith's crusade and threatened march on Westminster that finally forced Norman Lamb's hand. It was the thousands of aggrieved and bereaved loved ones of the victims of these terrible wrongs that have proceeded, raising their angry voices to be heard - who were at last being given a voice and in realisation that they had a voice and were not alone!

Even then, Mr. Lamb denied all knowledge of the CQUINs!

DOH and EoLC publications and reports are freely available on-line to view. They do change their weblinks, and have done so since this was last reported on these pages, but they are still trackable. For example, The DOH End of Life Care Strategy Third Annual Report -

Page 8 begins –

"Dear Secretary of State..."

On page 57, this can be found -

"Liverpool Care Pathway - CQUIN 

A CQUIN for the Liverpool Care Pathway (LCP) was introduced into acute contracts within NHS South Central for 2009/10. This has led to an increase in the number of people dying on the pathway and in the education of staff on the LCP."

This clearly states: CQUIN payments have resulted in an increase in the number of people dying on the pathway...

This clearly states that staff have been 'educated' in the use of LCP...

"Dear Secretary of State...", did you not confirm this with Mark Roland at his email - mark.roland@porthosp.nhs.uk?

"Dear Secretary of State...", how could you not have known?

"Pathways are used all over the NHS. Basically, they're sets of guidelines that prompt doctors and nurses to use the best tests and treatments."


The 'best tests and treatments" prompted by the pathways that are used "all over the NHS" are not necessarily the best but the most affordable. Hence, the decision to use the Liverpool Care Pathway...!

However, the Liverpool Care Pathway is not used to 'treat' either dying patients or patients diagnosed as dying. 

That point is made most clear and insisted upon by those who practice the LCP - 'practice' being the operable word, perhaps! The LCP is not a 'treatment' for, if that were the case, the practitioners of the LCP would be liable for prosecution.



"But the LCP isn't the only way of caring for dying patients."


The Liverpool Care Pathway is not used to care for dying patients but patients diagnosed as dying. Diagnosis may proceed via the SPICT or the GSF recommendations, for instance.


"Mrs. Vine was admitted to hospital with a dislocated shoulder. She developed pneumonia but was never diagnosed with a terminal illness."

Patients placed on the LCP are not being diagnosed, necessarily, with a terminal illness but diagnosed as 'dying'.



[The LCP] "was badly needed says Irene Higginson, Professor of Palliative Care at King's College, London: The problem that the Liverpool Care Pathway was trying to fix was most people do, in fact, die in hospital and it was well known that it wasn't of good quality."

Irene Higginson calls for better palliative care in hospitals. Irene admits to a problem with this at The Solid Facts: Palliative Care -

"The report highlights a myriad of challenges of mainstreaming palliative care: the fact that most common chronic diseases (unlike cancer) have uncertain prognoses, which makes assessment of the need for palliative care difficult...""The Solid Facts: Palliative Care" edited by Elizabeth Davies and Irene J. Higginson

What is certain is that what is needed is better care, full stop. Where there is better care there are always better outcomes. 

The Telegraph reported on a study in The Lancet which demonstrates this to be the case using the illustration of cardiac op outcomes. Patients are placed at risk because of a "one-size fits all" approach that is "ingrained" in the NHS. This is interesting. This study is a very good argument against pathways in general and, coupled with Irene's point above, palliative care pathways in particular.

"Twenty minutes away, in our hospice, when people are going through that dying phase, that area of care was done very well. We had the right programme for the patient, we had communication with the family, and if you get that part of the process of care right, then the patient can have the right symptom control and the relatives can have the right level of psychological....support in that environment. So, the idea was could we not translate what we see in the hospice 20 minutes away into this chaotic dying process that we had in hospitals? So that's when we sat down and we spent six months developing the first integrated care pathway for the dying patient." - John Ellershaw

Mr. Ellershaw, there is only one response to this. I will say just two words. These two words are a name. That name is Jack Jones.

You may read more here.

You disgusting people.

"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely..."

A lovely "end of life nurse" who is trained in grooming counselling. Fortunately for Mrs. Vine, the drugs had taken insufficient effect. She woke, that saved her life. That "lovely end of life nurse" would have persisted with his charm until he had succeeded in grooming his subjects into planning the funeral.


"The hospital told The Report that when a decision is taken to start using the Liverpool Care Pathway, a patient is closely monitored"

On The Big Questions, Dr. Philip Howard asked:

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.


"Some of the fiercest critics of the Liverpool Care Pathway do come from a pro-life perspective."

Some of the “fiercest critics of the Liverpool Care Pathway” have been the relatives and loved ones of its victims!

Helen Grady - Have they done it better in other countries? Have they been tougher about training and monitoring?

John Ellershaw - I think they are more systematic in their implementation and methodologies than other healthcare systems

Helen Grady - Than here?

John Ellershaw - Laughs [Public schoolboy stifled snigger, snort, snort!]

At the suggestion of ineptitude of British healthcare professionals in regard to the application of the LCP, little Johnnie splutters a little snigger.

Well done John. A medical holocaust has proceeded, and you snort a little snigger; you chortle a little chuckle.

They just walk past and turn their heads away in hope, perhaps, that it will just go away.

We stand in shock.

You disgusting people.

Consider this: if they had succeeded in doing what they had set out to do, Kathleen would be dead. That would be murder.

Thankfully, they did not. Still, should not a charge of attempted murder be served upon these individuals, or have they truly been served with a licence to kill...?