Negative media coverage of the Liverpool Care Pathway (LCP) in recent months has been incredibly unhelpful, spreading fear and confusion amongst patients and relatives. A small number of well-publicised failures to use the tool properly have led to a widespread smearing of its name. Some media coverage has approached the hysterical, with implications that certain doctors are killing off patients in a Nazi-style cost-saving project that amounts to covert euthanasia.
So it was good to be able to set the record a bit straighter at the Annual Representative Meeting of the British Medical Association in Edinburgh last week. The ARM is the BMA’s annual policy-making engine, and motions passed there become official policy of the organisation.
Hundreds of potential motions are submitted for the ARM around three months previously so they can be whittled down by an agenda committee to find those deemed most appropriate to debate. It is always tricky trying to judge in advance which issues will be given debating time; this is especially the case in the ethics section, where a large number of contentious issues are put forward for debate.
This year the frenzy around the LCP came to the forefront and the timing worked quite well as the government-sanctioned Independent Review of the LCP under Baroness Neuberger is considering its judgment.
I spoke to propose the motion (see below) and highlighted the following issues:
Amongst the media frenzy, there were some valid points. Relatives unaware that their family member was on the LCP; senior clinicians unaware that their patients were on the LCP; patients left on the LCP for weeks without any re-evaluation. This led to many patients and relatives being fearful about end of life care.
But many of the current concerns were dealt with by the last revision of the LCP in 2009. LCP version 12 states that it is ‘only as good as the teams using it…it involves regular assessment…reflection, challenge, critical senior decision-making and clinical skill.’
What’s new is the allegation that NHS organisations have been financially incentivised to increase the percentages of dying patients placed on the pathway. This risks a tick-box culture where clinicians may be tempted to feel that the job is done simply by ‘getting the patient on the LCP’ – regardless of whether it’s appropriate.
The Neuberger Review has much to consider, and various organisations have submitted evidence to it. In the majority of cases, the problems highlighted seem to be much more about the poor use of the LCP, rather than inherent deficiencies in the tool itself. The terms of reference for the Neuberger Review state:
The LCP is clear about the importance of communication. It is designed to support professionals, who may not be palliative care specialists, to provide personalised, hospice style-care. It encourages staff to anticipate the treatment an individual may need, and to be ready to provide it swiftly, but it does not dictate the treatment anyone should receive. The issue is therefore not about the merits of the LCP itself, but about how it is being used.’
The last sentence is the critical one. By far the main issue seems to be ensuring that tools like the LCP are used well, not just rolled out blindly.
Baroness Ilora Finlay, Professor of Palliative Medicine at Cardiff University, highlighted a few practical issues with the LCP, especially how the term ‘pathway’ can be unhelpful, sometimes implying a one-way street to death, when patients can sometimes improve and be taken off it quite appropriately (around 3%).
Baroness Neuberger’s conclusions, expected in mid-July, are eagerly awaited, and no doubt will contribute to further clarity in the use of end of life tools such as the LCP. I suggested that the following things are needed in this debate:
Firstly, Training – In order to prevent the misuses of the LCP highlighted in the media, it’s essential that all staff using it or similar end of life tools know the principles of how they should be used. This needs to be generic enough to accommodate any future changes in the LCP, or areas that prefer using a different tool.
Secondly, Quality – Some of the incentives for hospitals to use the LCP are said to have rewarded a purely numerical increase in use of the LCP, with little way to ensure it is increasing quality rather than simply quantity. This must be addressed in any future schemes to encourage use of the LCP or similar tools.
Thirdly, Communication – Poor communication came up repeatedly in the negative media reports. Patients and relatives need to be well informed about the LCP – what it does, and what it doesn’t do. And they need to be able to know how to communicate with clinical teams if they have concerns about any aspects of the care they or their relative are receiving.
Fourthly, Accountability – There must be systems to identify and reduce poor quality usage of end of life tools such as the LCP, either by individual clinicians or by organisations.
Let’s hope that the review will restore confidence in end of life care, and lead to improved use of tools like the LCP. I closed my speech with the following words:
The LCP may not be perfect, but it can be an excellent tool, and if it’s used well then it will continue to serve the needs of dying patients.
All parts of the motion were passed by a large majority. See below for the full text of the motion as passed.
The debate webcast can be watched online – listening from 41:11.
The full text of the motion as passed:
That this Meeting:-
i) notes that recent adverse media coverage has caused some patients and relatives to lose confidence in the Liverpool Care Pathway (LCP);
ii) affirms the value of the Liverpool Care Pathway in delivering excellent end of life care for dying patients;
iii) believes that strategies to implement the LCP must reward quality of care and not the frequency of use;
iv) supports the appropriate use of the Liverpool Care Pathway and palliative care in the UK;
v) requests that teaching in using end of life care pathways should be part of all medical school curricula.
Posted by Dr Mark Pickering
GP in Yorkshire, and CMF Board Member