The Liverpool Care Pathway – half the truth can be worse than none

The Telegraph has recently been waging a campaign against the Liverpool Care Pathway, their most recent shot a few hours before I started writing.  And regrettably the campaign seems to have legs – I’ve caught the Social Welfare Union falling for it tonight. (Needless to say The Daily Mail is taking it to extremes).

The campaign itself is true but dishonest.  True in that statistics like “At many hospitals more than 50 per cent of all patients who died had been placed on the pathway and in one case the proportion of forseeable deaths on the pathway was almost nine out of 10.” are perfectly true.  Dishonest because there’s one thing that modern medicine hasn’t been able to change.

People die in hospitals.

I was shocked, shocked to find that out.  And sometimes the doctors realise that there is nothing they can do – the patient is either going to die or recover.  If there is nothing more the doctors think they can do medically for a patient this doesn’t mean the patient has no needs.  They need to preserve the patient’s dignity and make them as comfortable as possible.  This is when they have two major choices.  Either to leave patients alone to die or to care for them as best they can while they are dying.

The best practice method for caring for patients for whom there is no further treatment possible is called … The Liverpool Care Pathway.

It came out of best practice Hospice care (hospices specialising in the care of terminally ill patients) and is intended to give the benefits of that best practice to doctors and nurses who very rarely see dying patients – so need the guidance.  (It’s also used in hospices, nursing homes and other environments; clinical care pathways are a good thing).  And yes, some PCTs do reward hospitals for providing best practice care for dying patients rather than just leaving them in a bed to die.  This is meant to be a bad thing?

Of course as the Liverpool Care Pathway is for patients the doctors have done all they can for medically, it is unsurprising that most patients who die at many hospitals go on the pathway – and an overwhelming proportion of forseeable deaths.  But the most clueless quote from the media on the subject belongs to the BBC (admittedly as a quote).  “We don’t leave animals which are sick just to die without medication, we don’t just leave them to die of their own causes, so why do that to humans?”  The answer to the question, to be brutal, is that we take sick pets to the vet to be put down.  Is that the standard of care those opposed to the Liverpool Care Pathway want?

For further reading, there’s the implementation guide and the official FAQ.

And on a final note from the FAQ

Does the patient or relative need to give written consent to use the LCP?
No, the LCP is not a treatment but a framework for good practice, therefore, written consent is not required. However, identifying that someone is in the last hours or days of life and agreeing a plan to support care in the last hours or days of life should be discussed with the patient where possible and deemed appropriate and always with the relative or carer.

How will a relative or carer know if the LCP is being used?
Acknowledging that a patient is dying and making the decision to use the LCP to support care in the last hours or days of life should be discussed by the clinical team, with the  patient where it is possible and deemed appropriate and always with the relative or carer, in accordance with GMC best practice guidance (GMC 2010). All significant conversationsshould be supported by appropriate written information about the LCP.

Therefore there should never be an occasion when the relative or carer who is named as the first contact or next of kin is unaware of the diagnosis of dying or of the subsequent care plan.

These cases where the relatives haven’t been told they are either not primary relatives or carers or the Liverpool Care Pathway hasn’t been followed.  (And the “opt out cards” are simply telling doctors and nurses to follow the Pathway).

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3 thoughts on “The Liverpool Care Pathway – half the truth can be worse than none

  1. “Always” tell the relative or carer? I’m assuming this means when the patient has no capacity (which is most of the time I guess, if they are dying), but it is still a breach of confidentiality if the patient does not want that.

  2. My objection is simply that by all accounts the ‘care pathway’ involves withdrawing fluids – and thirsting to death is a horrible way to die. Even if you’re unconscious, if you’re not brain dead you can still suffer.
    ” The answer to the question, to be brutal, is that we take sick pets to the vet to be put down. Is that the standard of care those opposed to the Liverpool Care Pathway want?”
    Seeing my cat be put down convinced me that euthanasia can be a good thing, yup. But in general I favour the hypocritical tradition of overdosing the patient with morphine ‘to ease pain’ – with the side effect that they also die more quickly. Definitely beats being thirsted to death.

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