Sunday, 8 August 2010


The Liverpool Care Pathway (LCP) was introduced in the late nineties by the Liverpool Marie Curie Hospice and the Royal Liverpool University Hospitals NHS Trust palliative care teams. It is an integrated care pathway; its aim is to better equip those who care for patients in the last hours or days of life with necessary skills and in doing so, enable a peaceful, pain free death.

The LCP Continuous Quality Improvement Programme incorporates the following aims:
  1. AIM To improve care of the dying in the last hours or days of life.
  2. KEY THEMES To improve the knowledge related to the process of dying. To improve the quality of care in the last hours or days of life.
  3. KEY SECTIONS Initial Assessment. Ongoing Assessment. Care after Death.
  4. KEY DOMAINS OF CARE Physical. Psychological. Social. Spiritual.
The aims are laudable and provide holistic care to those at the end of life, and I am certain that it offers a peaceful, pain free release to those in the process of dying. Originally developed for the care of cancer patients, it has since been adapted for patients with other terminal conditions. It is now used in hospitals, hospices, care homes and within the community.

But with all good things, it is open to abuse. Disquiet is in the air. Adrian J. Treloar, physician expressed concerns' in the BMJ here in 2008 and Ronald J. Clearkin here in May of this year. Prof. Peter Millard, Dr. Peter Hargreaves et al wrote to The Telegraph here in September last year.

The LCP is a tick box document despite Marie Curie's insistence that it is not. The following criteria must be met before commencing the LCP: the patient must be bed-bound, semi-comatose, only accepts sips of fluid and is unable to take tablets. I have read over and over again while researching that diagnosing dying is not always easy.

Prof. Millard et al raised the following points in their letter:
"Forecasting death is an inexact science."

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

"... the diagnosis could be wrong."

"It is disturbing that in the year 2007-2008, 16.5 per cent of deaths came about after terminal sedation.

Experienced doctors know that sometimes, when all but essential drugs are stopped "dying" patients get better."

Please note: The total number of people receiving continuous deep sedation is twice the rate of the Netherlands where there exist a culture of a casual approach to death and legalised euthanasia. At times, is the LCP euthanasia by the back door?

In 2009 a survey by the Royal College of Physicians and the Marie Curie Palliative Care Institute in Liverpool obtained details of almost 4000 treated on the scheme in 2008 and found:

The average age was 81 and they were typically on the pathway for 33 hours.
39% suffered from cancer, while others had conditions such as stroke, organ failure, pneumonia and dementia.

More than a third were given sedatives and four out of five did not need intravenous meds or fluids - or had them withdrawn,

28% of relatives were not informed that their loved one was on the pathway.

However, this survey found the implementation of the pathway encouraging, highlighting only that information - or the lack of it - given to relatives needs addressing.

Please read the following two articles: one two . There are several more stories on timesonline but unfortunately they won't 'save.'

When our residents are admitted to hospital, it is mostly with a diagnosis of pneumonia. As said in my first post on Anticipatory Care Planning - forecasting who will placed on the LCP is almost an exact science in my work place! Will they end up on the LCP or won't they? It depends very much on the support system of relatives; if your relatives are strong and will fight for you - it is doubtful that you will end up on the pathway; if your relatives are compliant and open to suggestion or you have no NOK - the odds are you will be placed on the pathway; if you have behavioural/management problems - you will be sedated and thus will cease eating and drinking and will be placed on the pathway; if you can't feed yourself and have no strong support from relatives - you're screwed!

If any of the aforementioned applies and you are young - the odds are you won't be placed on the pathway. Being old definitely works against you.

Prof. Peter Millard has said: "The risk as this is rolled out across the country is that elderly people with chronic conditions like Parkinson's or respiratory disorders may be dismissed as dying when they could still live for some time."

The problem with the LCP is that it focuses on the initial decision as to whether the patient is thought to be dying. If the answer is "Yes" then the entire process becomes automatic. "How can we make you comfortable?" has become "This is how we will treat you while you die." It is an ethical shift.

When used as it should be - and hopefully this is most of the time - the LCP is a fine, wonderful thing. But I fear it has become tainted.
Anna G


Mr x said...

It is an ethical shift, from treating the ill to playing God. Worse still if the aim is just to save money! This is not right and will eventually haunt those staff members who perhaps feel forced to participate, or else!

The Witch Doc touched on this subject before, so if you are both, and the other docs and profs who voiced their doubt on professional and/or national newspapers, feel that uneasy about it, then their definately is something wrong. No smoke without fire!

Keep talking Anna G

Hypercryptical said...

Thank you for your comment Mr X.

I shall keep on talking - lots more to research yet!

While researching for this post I did come across a NHS site where "reductions in costs to Trusts" is mentioned in a particular circumstance.

It will be detailed in a future post.

Anna G

Dr No said...

Excellent well-balanced post. The LCP can be excellent - and at the same time is wide open to abuse/misuse (both intentional and unintentional), which is of course what makes it so tricky. We don't want to throw granny out with the bathwater.

What I find especially disturbing is its potential to become self-fulfilling for those who lack relatives and/or advocates. The pragmatic effect of this is that life does not so much have value of itself, but more by way of those in whom it is reflected.

Of course social interaction is important - but it should never be the arbiter of death.

The costs question is a no-brainer: dead patients are cheap patients...the question is: has anyone taken this out of the debating chamber and onto the wards?

Hypercryptical said...

Thank you Dr. No.

The answer to your last paragraph is in some circumstances - Yes!

I shall continue to research in this area as I am sure there is more to find. I really hope I don't find it though.

Anna G

Dr Jr said...

Thanks for reading my post on the LCP. You've neatly distilled the LCP into a post and yes, even as a new doctor starting out, I've always been wary of the LCP itself.

I think my case is a fair use of the protocol, however, as you point out, I do feel it is abused as a shortcut to "legal" euthanasia at times.

I get the impression my Care of the Elderly team don't use it as such, but I've heard of plenty of suspicious cases - a friend of mine's grandmother was a "victim" of wrongful use of the LCP. Although she wasn't well, she was placed on with little explanation of what it actually was. When they requested her notes after her death, her morphine dose had been tipp-exxed out and written over. I'm not sure what happened afterwards, but this is the kind of thing I fear. Tainted is exactly the right kind of word.

Hypercryptical said...

Thanks again Dr Jr.

I do fear that by the need for professional distance - we become 'immune' to death. I see this in myself and it worries me.

But I will fight this 'coldness' in me - to the death ironically! I will fight for those who for death is not ready!

Hypercryptical said...

Hey! Thank you Dr Jr - just noticed you as my first follower!

I am honoured! :0)

Anonymous said...

I was informed by a staff nurse the day my father died that he was on the Liverpool Care Pathway. This was later denied by the hospital. It haunts me to this day as to what exactly happened during his final hours. The system is very open to abuse as far as I am concerned.

HyperCRYPTICal said...

Thanks for your comment anonymous.

I too, remain concerned that the LCP is open to abuse. This and the other LCP post have visits everyday and that worries me - as all the search words are rarely complimentary.

If you want to email me and tell me your concerns I would appreciate it as I would like to gather 'evidence' of possible abuse. You can be assured that the contents of your email would be strictly confidential.

When used as it should be - the LCP is a wonderful thing - but as said, I am really unsettled by its potential for abuse.

I truly hope you have found some sort of peace.


Anonymous said...

From what I have seen in various hospitals, especially those with no end of life ward, is that many patients ARE being given deep continous sedation until they die of dehydration. This is especially true of the elderly and those with other health problems such as dementia and related illnesses. My own mother was refused treatment for Pneumonia and instead put onto the Liverpool pathway. She had Dementia but prior to contracting the chest infection, had been eating and drinking normally. She died six days later without being given any chance to recover. Maybe she wouldn't have survived but she should have been given the same chance as anyone else. The NHS writes off anyone with, what they consider a 'terminal' illness and I'm pretty sure the government turns a blind eye - why else is nothing being done about it.

MrK said...

My mother died on the 'LCP' and was simply not given treatment for a partially blocked stomach. She was denied water in a way she could take in. From the autopsy it is clear that if she had an emetic and even chicken soup let alone a drip, she would not have died that day, or that way. And the doctors lied about her condition, making claims they had no hard evidence for. The autopsy report says she "died after palliative care".

At the time, it looked like murder, and thinking back about it, it still does. They should be prosecuted, but there doesn't seem to be any precedent for a class action for instance against the LCP.