Liverpool Care Pathway - Identification, Identification, Identification

On parade, the usual suspects and the LCP lives!






Mr. Patrick Gordon Walker's landmark observations still echo down the years...

The End of Life Baseline Report published in 2011 warned of a "Tsunami of need".

Just last year, Hartlepool Care Home Managers forum held a Study day, The Elderly and the Time Bomb Conference, to address EoLC following the phasing out (sic) of the LCP.

Liverpool Care Pathway - The Final Countdown... And Counting

The length and breadth of the land, the portent of a demographic debacle is the motivating raison d’être in implementation of every EoLC Strategy.

This is NHS Shetland –

The population of Shetland is ageing. Figure 1 below shows how we predict that this will continue, with the number of 75+ expected to more than double by 2035. A population who live longer are increasingly likely to be living with a range of long term and progressive conditions. Currently, on average 213 people in Shetland die each year. The majority of people who die are over the age of 65 (87% in 2011) and 80% of these deaths are preceded by a period of illness or increasing frailty.

The EoLC Strategy was published on 16 July 2008 under the 2005-2010 Labour Administration.

The Strategy was implemented and rolled out. It has since been continued with zeal by the Coalition.

The DoH invited the National Council for Palliative Care (NCPC) to groom the British public into accepting the idea of dying as a positive life choice. Out of this was formed the Dying Matters Coalition. The NCPC has led the Coalition since 2009. The EoLC Program was effectively outsourced to the NCPC.

In their own write: "The National Council for Palliative Care (NCPC) is the umbrella charity for all those involved in palliative, end of life and hospice care in England, Wales and Northern Ireland".

In 2009, the NCPC set up the Dying Matters Coalition to promote public awareness of dying, death and bereavement. It is chaired by Professor Mayur Lakhani, who is a practising GP and author of the Lakhani Recommendations. The Lakhani Recommendations are now protocol.

The work of the Coalition is supported by the NCPC’s Board of Trustees.

It has done its work well...

The New Statesman asked: Why are old people in Britain dying before their time?

The BBC asked: Where are the missing 90-year-olds?

Liverpool Care Pathway - Reports And Reports Of Reports

This does not moderate their zeal; on the contrary, it only excites their determination and their predictions remain steadfast and dire...

NHS Shetland –

And LCP lives...!

Priorities set in 2009

• Implement a localised Integrated Care Pathway for the dying based on the "The Liverpool Care Pathway for the Dying Patient‟ (LCP) which facilitates regular re-assessments towards the end of life
• Ensure that all professionals know how to access equipment for adults and children at the end of life and arrange for its delivery
• Develop the skills of professionals to recognise when a patient might be nearing the end of life.
• Develop and implement a Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) Policy to support the process of making resuscitation decisions.

 Current position (2013)


• A localised Integrated Care Pathway for the dying based on the "The Liverpool Care Pathway for the Dying Patient‟ (LCP) was introduced in 2011 and is monitored on a regular basis
• Training has been put in place to support the LCP and to ensure that there is a consistent approach when using the pathway and recognizing when someone might be nearing the end of life
• Inventories of equipment have been put in place so all professionals know how to access and arrange delivery of equipment
• The national DNACPR Policy has been implemented, with regular review of compliance with the DNACPR assessment process being undertaken by medical staff. Other policies with training for staff have also been implemented to support individuals to understand their rights and make decisions about their ongoing treatment e.g. through the Adults with Incapacity (Scotland) Act 2000 and the Resuscitation Planning Policy for Children and Young People (2010)
• There has been an increase in the number of Non Medical Prescribers (e.g. nurses and pharmacists) who can independently prescribe medicines making it easier and quicker to provide appropriate medicines for people with long term conditions or palliative care needs. Symptom control has also been improved through the availability of the “Just in Case Boxes‟.

Going Forward (2013 - 2016)

• Continue to implement integrated approaches to support people who are in the dying phase of their life, including the LCP or other structured, individualised care plans as appropriate.
• Continue to implement systems to review and monitor the care standards set out in the integrated pathways so that improvement ideas can be identified 23 and implemented (e.g. quality of record keeping, undertaking case reviews in the primary care setting and the hospital, undertaking significant event analysis when needed, monitoring patient and family inclusion in care planning, monitoring the DNACPR assessment process etc).
• Implementing all of the other recommendations and principles in this strategy which come together to make a holistic plan to support people at the end of their life.

Performance targets have to be met against National Indicators.

Performance Indicators are a measure of ‘how well we are doing’.

Those who seek are sure to find and those ‘skilled’ to recognise when a patient might be nearing the end of life are sure to seek them out and find them.

• There has been an increase in the number of Non Medical Prescribers (e.g. nurses and pharmacists) who can independently prescribe medicines making it easier and quicker to provide appropriate medicines for people with long term conditions or palliative care needs. Symptom control has also been improved through the availability of the “Just in Case Boxes‟.

Those who seek are sure to find and those ‘skilled’ Non-Medical Prescribers who 'recognise' that a patient might be nearing the end of life are sure to ease them into a 'good' death.

The BBC asked: Where are the missing 90-year-olds?

Mr. Patrick Gordon Walker’s landmark observations echo down the years.

There are always consequences. A programme or strategy promoted and rolled out by government will multiply those consequences. There have been "excess deaths". There are "missing" older adults. Where are those missing ninety year-olds?

They will (of course!) trawl in many who would not have formed part of the One Percent cohort they are exhorted to seek. By far the greater part of medical error consists of medical misdiagnosis. There will be excess deaths...

Palliative Care Performance Indicators

Palliative care performance indicators were published in 2013 by Healthcare Improvement Scotland, which provides a clear set of outcome measures for the provision of palliative and end of life care in Scotland. 

The intention is that the data to demonstrate performance against these outcome measures will be taken from routinely available information already provided to Information Statistics Division (ISD) and the results will be represented to Health Boards to be included in the clinical governance arrangements and future planning of services. 

The indicators are shown below and will form part of our local performance scorecard for palliative care and end of life care.

• Indicator 1: Increase in the number of people with palliative and end of life care needs who are identified
• Indicator 2: Increase in the number of people with palliative and end of life care needs who are assessed and have a care plan
• Indicator 3: Increase in the number of electronic palliative care summaries accessed
• Indicator 4: Place of death

Increase in the number of people with palliative and end of life care needs who are identified...

Indicators must and will be met and exceeded as marks of performance

and NHS Scotland has its own, home-grown version of the GSF (naturally).

The SPICT –

This is the ‘tool’ they will use to ‘identify’ their 1%. Top of the list, at number one, is the Barton Method:

1. Ask
Would it be a surprise if this patient died in the next 6-12 months?

The ‘surprise question’.

Identification, identification, identification.

If this was a police identity parade, it would be called a 'stitch up'!

QOF, QOF!

2013 was the halfway point of the 10-year 2008 End of Life Care Strategy. To mark that, the National Council for Palliative Care (NCPC) held a conference “Refreshing the strategy. The next five years for end of life care: what do we need to do?” 

Liverpool Care Pathway - What Is To Be Done...?

We are almost there but they are not quite finished yet.

With the acceptance of the idea of dying as a positive life choice, euthanasia or ‘assisted suicide’ has become popularised.

It is now in the main stream.

Additional reading -

Liverpool Care Pathway - Of CQuINs, Tipping Points And QUELCAs

Liverpool Care Pathway - The Werther Defectives

Liverpool Care Pathway - Time To Wise Up

Liverpool Care Pathway - When The Caring Had To Stop

Liverpool Care Pathway - Hard At Their Purpose

Liverpool Care Pathway - Recruiting And 'Transforming'!

Liverpool Care Pathway - The Three Options: A Post-modern Fairytale