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A better pathway to dying

04 January 2013

THE image of the Grim Reaper might have been seen off with the old year, but the fear of death is not so easily discarded; nor are arguments about how it happens in hospital. The Liverpool Care Pathway (LCP), a protocol for the care of dying patients, is once more in the news, partly because of financial incentives given to hospitals nationwide as they implement it.

Medical staff are, of course, mortal (consultants excepted), and exposure to illness and fatality does not make them immune from the normal anxieties about death. Indeed, anecdotal evidence suggests that they might be more susceptible as a result. This is coupled with a professional objective of restoring every patient in their care to health. In hospital, death is a failure. As a consequence, a gulf has developed between hospital and hospice care - the latter being a completely different, multidisciplinary approach that uses medicine as just one part of the care. The LCP is a checklist for the last three days of someone's care, as far as anyone can predict. It prompts the team of clinicians, social workers, and chaplains to consider carefully which actions and treatments (including artificial nutrition and hydration) will allow the patient to die with dignity, and which are futile or, worse, cruel.

No course of treatment is prescribed. It is not "designed to finish people off double-quick", as was reported by one middle-market tabloid newspaper that has taken against the scheme. Patients are not "put on the LCP" by doctors, so much as recognised to be dying and therefore better served by the kind of questions the LCP asks of the team. The decision that someone should be on the LCP is also reversible, as a patient's condition can improve.

One of the key items on the LCP checklist is communica-tion with the patient, if possible, and with the family; and it is not surprising that this has been the source of most diffi-culty. Counselling families, in a way that enables them to hear and understand, calls for words that are not always part of the clinician's lexicon, and doctors rarely have the time to listen well. Behind many of the complaints about the LCP can be found staff who are too busy, too stressed, or too afraid.

The compassion that the Liverpool Care Pathway brings to end-of-life care is to be welcomed; but compassion costs time, and time, in the Health Service, costs money. It is asking much of NHS hospital staff to develop the spiritual skills of unhurried communication more often found in independent hospice care. Hospitals would do well to draw on the spiritual resources of their chaplains and of hospice workers, to enable their staff to face the reality of death, and to try to help patients to die well.


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