Decision to jettison end of life Liverpool Care Pathway 'too extreme'

The decision to jettison the approach to care of the dying, known as the Liverpool Care Pathway (LCP), was "too extreme," given that its principles are widely regarded as among the best examples of palliative care in the world, argues a senior ethicist in the Journal of Medical Ethics.

The LCP, which was intended to transfer the principles of hospice care to hospitals, fell foul of poor application by healthcare professionals and widespread misunderstanding of its scope and purpose among the general public, argues Dr Anthony Wrigley of the Centre for Professional Ethics at Keele University.

The UK government decided to abandon the LCP last year following an independent review it commissioned in the wake of persistent media reports, suggesting that the LCP was deliberately being used to hasten the end of life rather than ease suffering.

The Neuberger Review recommended the LCP be phased out and replaced with individually tailored care plans after identifying that it had been associated with poor communication with relatives and a failure to treat patients with compassion and/or dignity.

This was despite extensive published evidence showing that its correct use improves end of life care, and widespread endorsement by professional bodies, Dr Wrigley points out.

"One reason why this [recommendation] seems too extreme is that end of life care in the UK is of a quality that is world-leading, recently being ranked as having the best overall in the world," he writes.

There was widespread agreement that before the introduction of the LCP, "poor care and suffering were the norm for patients dying in hospitals," he adds.

The LCP was always intended as a framework to support to provide holistic care tailored to the individual's needs in their last few hours or days; it was never intended to replace ethical decision-making, he emphasises.

Some of the most common complaints levelled against the LCP were that it denied food and water to the dying, irrespective of the patient's desires, causing untold distress to the patient and his/her relatives.

The LCP does not recommend this at all, quite the opposite, says Dr Wrigley. And it recommends the use of morphine to relieve pain, not to hasten the death of the patient, as has come to be believed. Furthermore, it says that the patient's relatives should be involved in the decision to administer morphine - a recommendation that some hospital staff apparently ignored.

"That were purportedly using a care pathway that explicitly states the importance of good communication, highlights an underlying problem over care provision in hospitals rather than with the LCP," he points out.

He suggests that scrapping the LCP because some people didn't know how to apply it properly is rather like recommending that morphine or insulin be phased out because some people don't know how to use these properly.

A much better approach would be to keep the LCP but recommend proper training on its correct use and on how best to talk to the relatives of those put on it, he suggests.

"Seeking to end an approach that is widely seen as best practice and which can genuinely deliver because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care," he concludes.

More information: Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review, Online First, DOI: 10.1136/medethics-2013-101780

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