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Not to be confused with euthanasia

19 April 2013

The Liverpool Care Pathway for dying patients has received a mixed press. Terence Handley MacMath explains its workings

SHUTTERSTOCK

Caring approach? The Liverpool Pathway prevents
a dying patient from being treated aggressively

Caring approach? The Liverpool Pathway prevents
a dying patient from being treated aggressively

ARGUMENTS over the implementation of the Liverpool Care Pathway (LCP) in hospitals have been so insistent of late that a review has been been ordered by the Health Minister, Norman Lamb. It is being chaired by Baroness Neuberger, and it should be published this year. But what is the LCP, and why has it engendered such fuss?

As the independent hospice movement was coming of age, more and more people began to ask questions about the experience of dying in hospitals. The independent hospice movement had shown, to the tiny section of the population that it could accommodate, that compassionate, multi-disciplinary attentiveness could enable death to be a positive experience, both for patients and their carers.

In the late 1990s, the Marie Curie Hospice in Liverpool, and the Royal Liverpool Infirmary collaborated on a project that would help hospitals to change the way that the majority of us die.

They produced a tool called the Liverpool Care Pathway, which would encourage hospitals to stop treating a dying patient "aggressively", and allow death to happen as naturally and painlessly as possible. The tool prompts staff to question how they are to manage the patient's pain, agitation, respiratory-tract secretions, nausea and vomiting, and shortness of breath, as well as addressing wider care needs, such as communication with the family, the wider psycho-social team, and chaplaincy.

SINCE its introduction, it has been refined several times. It has been approved by the National Institute for Health and Care Excellence (NICE), and so far has been implemented in 85 per cent of NHS Trusts.

Surveys of doctors and nurses report a perceived improvement in the way that dying patients are treated in hospital, but there has been a storm of protest, reported in the press, which has suggested that it is both badly implemented and intrinsically flawed.

The suggestion that the LCP is "euthanasia by the back door" has been heightened by the fact that implementing the LCP is one way in which trusts may earn money under a system known as "Commissioning for Quality and Innovation".

Jargon may be another reason why journalists and families find the LCP suspicious, or even wickedly euphemistic. In NHS-speak, a "tool" is not an instrument to effect something, but rather a checklist to try to ensure consistent, objective, equal treatment for all patients, although they are being treated by different staff whose own approach may vary according to energy, distractions, etc. (Some have even devised "spiritual assessment tools", for what they're worth.) "Pathway" also sounds sinister to some, though it is common NHS-speak to describe any patient's trajectory through illness and treatment.

ONE criticism levelled at the LCP is that in order to implement it in individual cases, there first has to be a decision that a patient is beyond hope of recovery. Which of us has the right or the expertise to predict someone's death? My observation is that doctors and nurses are the first to admit that this is a very difficult thing to do.

On the other hand, as organs begin to fail, there are often signs that the patient is dying. At this point it may be more compassionate to withdraw artificial nutrition or hydration, if the body's organs can no longer deal with food and fluids. It may also be compassionate to increase the dosage of pain-killing drugs, even at the cost of shortening someone's life. Using the LCP is a prompt to "go with the flow" at the pace dictated by the patient. There is also a built-in prompt to consider that the patient may be recovering - and recent surveys indicate that some three per cent of patients have been taken off the LCP, at least for a while.

ONE of the bitterest criticisms of the LCP has been that it is implemented without consultation with patients and families. Ironically, one of the particular jobs the tool was designed to do was improve communication and level out the distinctions between the medical, psycho-social, spiritual team, and the family, friends, and the patient, in the last hours of life.

Hospice care is far less hierarchical in spirit, and involves the whole multi-disciplinary team in looking after the patient. It has far more time to involve the family. Put bluntly, in a hospice there is usually more time for this, more willingness, and more experience and training, and this is what the hospice's independent funding achieves.

In a busy hospital, where staff must make difficult clinical decisions and interventions, it may be more difficult for doctors and families to communicate effectively. Having a checklist of questions that would be asked routinely in a hospice may challenge a busy hospital team to stand back and think. The hierarchy is asked to relax and shift a little: as with medical procedures, so with relationships.

If the surgeon or consultant's expertise is not needed, the most important person to the patient's well-being may be a grandchild, or nurse, or the ward clerk, or someone else who can give whatever emotional, physical, or spiritual comfort is needed.

Despite the need for all the patient's carers to consult with him or her (if possible), and with one another, families may misunderstand their position, even when they have power of attorney over health matters. This has come about because of the much more nuanced attempts to respect patients' wishes and rights in recent years.

THE introduction of "living wills" and "Do not resuscitate" orders give us the illusion that we can manage the manner of our own deaths, and it is now a common understanding that it is the family's right to decide what medical treatment is or is not given. But, for good or ill, it is still the doctor's right to decide when and how to treat a patient, in the patient's best interests - whatever the patient or next-of-kin wishes. It must be so; for it is the doctor who bears the responsibility, and must account for his or her professional actions.

As evidence emerges of the mistreatment of vulnerable patients in some NHS wards, from all levels of staff, it is understandable that a professional tool to ease death could be misconstrued as a conspiracy to hasten it, and those who look after the vulnerable are thought to be motivated principally by cash incentives. Sadly, the review will almost certainly reveal cases where, through ignorance, weakness, and even deliberate fault, patients on the LCP have been caused unnecessary suffering, because caring for dying people well is a costly art, and few of us have cultivated it.

As a chaplain who has worked in both an independent hospice and an NHS hospital, I believe that the anger and suspicion that have greeted the LCP are the natural response to death in an unnatural setting for three reasons: one timeless, and two contemporary.

THE first reason is that most of us are afraid of dying. Grief arouses strong emotions in us all, and among them are regret, guilt, depression, and anger. Finding someone or something to blame for our loss can distract us from our pain, if only temporarily. We have no dress rehearsal for helping our nearest and dearest through their death, and it is something that all of us want to do as well as possible, for their sakes.

The second is that recent media reporting of neglect in hospitals, particularly the events at Stafford Hospital, has affected trust in the medical teams and management charged with the care of the vulnerable.

The third is that if, as a society, we choose to give financial incentives to hospitals as a way of improving care in diverse areas, we should not be surprised if there is confusion about motivation and compassion.

The LCP as a tool, used in both a hospice and a hospital, is just that - a framework that presupposes that the multi-disciplinary team and family surrounding a dying patient will wish to support them as compassionately and skilfully as they can, neither hastening nor delaying death. Whether it is used as it is intended, or by people who cannot bear the cost of caring for the dying, will be the important question in every case.

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