COMMENTS ON
Department of Health
Review of the Liverpool Care Pathway for Dying Patients (LCP) - Public call for evidence
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the call for evidence on the Liverpool Care Pathway. The College has the following comments:
The Liverpool Care Pathway (LCP) is a structured clinical record that is a tool and aims to support clinical judgment and assist multidisciplinary teams in providing optimal treatment and care for patients who are dying i. It promotes regular review of patient and family needs and prompts clinicians to make decisions about treatment options but does not direct these.
The LCP is supported by paperwork that clearly lays out the responsibilities on staff - especially senior clinicians - to communicate clearly with families and to ensure that there is a shared understanding across the multi-disciplinary team and with the person and family that death is inevitable (but that in some cases people can improve).
The LCP needs to be used correctly to be safe and effective and, in the experience of our Fellows and Members, the LCP has generally led to significant improvements in delivering high quality patient and family care including good symptom control, family support and holistic care in different care settings. It has also enabled services to audit care outcomes for dying patients in a structured way that was not possible before.
Problems have arisen with shared decision-making about treatments - such as CPR, artificial hydration/ nutrition - and communication. In some cases this may have been due to lack of training about end of life care and insufficient leadership by senior clinicians. It is important that doctors caring for people at the end of life have a clear understanding of how to apply the comprehensive guidance from the GMC on end of life care and the relevant sections of the Adults with Incapacity Scotland Act in clinical practice.
When the dying trajectory is more prolonged, or the outcome in a deteriorating patient is uncertain, it is reasonable to use the LCP documentation or a deteriorating patient pathway such as AMBER to record care. This includes an individualised anticipatory care plan and medications for symptom control as per approved palliative care guidelines. Treatments should be individually reviewed on a regular basis and given unless their side effects or risks outweigh any benefits - for example, if the patient develops terminal respiratory secretions. Treatments should clearly not be given if contrary to patient wishes - expressed at the time or documented clearly in advance.
There is some confusion about decision making in patients who lack capacity, although the current legal position clarified in this context by the GMC is that clinicians are directed to make "best interest" decisions about treatments informed by all the evidence available regarding the patient's wishes and having weighed up the benefits and risks.
Legally appointed proxies with welfare powers can consent to a treatment being given on behalf of a patient but cannot demand one that would not have a medically successful outcome. Close family members should be involved in discussions about the patient's care plan and the likely prognosis, but not asked to consent to treatments that would not benefit the patient. The LCP is not a treatment.
All families want the best for their loved one. Grief reactions are powerful and a good reaction will follow a “good death” while a mismanaged death will result in a high level of distress. Different people, however, have different ideas on what makes a good end of life experience.
There is no evidence that the Liverpool Care Pathway itself is flawed, but its effective use depends on clinicians being able to identify people approaching the last hours and days of life. The pathway initially used signs from the trajectory of rapid decline typically associated with dying from cancer - reduced consciousness and poor oral intake and performance status. The current version advises that the process of dying is different for different patients, particularly in people with non-cancer illnesses ii. Making the care individual to each patient is key to success.
The general view of the College is that the Liverpool Care Pathway is an effective and successful instrument, but it has been called into question recently due to problems in its application. It is a tool and it is only as good as the people who use it. The College therefore supports further training for professionals who are not specialists in palliative care so that this pathway can be used in a sensitive and patient-centred way, in addition to ensuring that all clinicians who work with dying patients and their families have appropriate communication skills.
i Kirsty Boyd and Scott Murray, Using end of life care pathways for the last hours or days of life
BMJ 2012; 345: e7718 doi: 10.1136/bmj.e7718 (Published 14 November 2012)
ii Ibid