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Liverpool care pathway should be phased out, independent review finds Liverpool care pathway for dying patients to be abolished after review
(about 2 hours later)
Doctors have used a controversial end-of-life care regime "as an excuse for poor-quality care", an independent review has concluded. The Liverpool care pathway is to be abolished following a review which heard that hospital staff wrongly interpreted its guidance for care of the dying, leading to stories of patients who were drugged and deprived of fluids in their last weeks of life.
Experts have recommended that the Liverpool care pathway (LCP) should be axed. But the government-commissioned review, headed by Lady Neuberger, found it was not the pathway itself but poor training and sometimes a lack of compassion on the part of nursing staff that was to blame, while junior doctors were expected to make life-and-death decisions beyond their competence after hours and at weekends. The review says individualised end-of-life care plans must be drawn up for every patient nearing that stage.
They say the regime should be phased out over the next six to 12 months and be replaced with a personalised end-of-life care plan for each patient. "Caring for the dying must never again be practised as a tickbox exercise and each patient must be cared for according to their individual needs and preferences, with those of their relatives or carers being considered too," said Neuberger. "Ultimately it is the way the LCP has been misused and misunderstood that had led to such great problems."
The LCP – which recommends that in some circumstances doctors withdraw treatment, food and water from sedated patients in their final days – has come under intense scrutiny. Reports have suggested that doctors have been establishing "death lists" of patients to be put on the pathway. She said it was too late to turn the clock back and salvage the LCP, which was devised to try to extend the positive experiences of dying hospice patients into the hospital setting. But in replacing it, the NHS must make care of the dying part of its core business, she said.
There have also been suggestions that hospitals might be employing the method to cut costs and save bed spaces. "What we have also exposed in this review is a range of far wider, fundamental problems with care for the dying – a lack of care and compassion, unavailability of suitably trained staff, no access to proper palliative care advice outside of 9-5, Monday to Friday."
But medics have argued that the pathway has transformed end-of-life care, saying it can offer peaceful, pain-free deaths when used properly. The review listened to harrowing stories from families who had not been told their loved one was expected to die and, in some cases, were shouted at by nurses for attempting to give them a drink of water. Nursing staff had wrongly thought, under the LCP guidance, that giving fluids was wrong. Some patients were put on the pathway and treatment was withdrawn, only for them to make a recovery, albeit temporarily. Communication had been very poor and medical staff had sometimes dodged painful discussions with patients and families, the review found.
The independent review into the regime found that while the LCP can offer "high-quality and compassionate care", there were too many cases where it was incorrectly implemented. The review strongly criticised the Nursing and Midwifery Council, which – unlike the General Medical Council, which regulates doctors – offered no guidance to nurses on the care of the dying. That must change "as a matter of urgency", said Neuberger.
The regime was introduced with the aim of helping doctors and nurses provide quality care for patients during their final hours and days of life. But, following criticism of the regime, health officials recently commissioned a review into the use of the LCP at hospitals and care homes. The review makes 44 recommendations, including the phasing out of the LCP over six to 12 months as individual care plans for the dying are brought in. It says that only senior clinicians must make the decision to give end-of-life care, along with the healthcare team, and that no decision must be taken out of hours unless there is a very good reason.
The review of the pathway, chaired by the crossbench peer Lady Neuberger, has heard evidence from patients, families and health professionals. It says there must be no incentive payments to hospitals to put patients on end-of-life care, as occurred with the pathway. This was intended to offer encouragement to adopt best practice but has been interpreted as payments to speed up patients' demise.
They concluded that there were "too many cases where the LCP was simply being used as a 'tick box' exercise".