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Gold, incentives and meh

GPs avoiding Liverpool Care Pathway 'due to adverse publicity', says RCGP

Exclusive Negative publicity surrounding the Liverpool Care Pathway is causing some GPs to avoid using it in patients nearing the end of their lives, the RCGP has told a Government review into the pathway.

The college said that the controversy surrounding the palliative care pathway in the press meant it has become a ‘barrier’ to communication with patients for some GPs and is often avoided.

The LCP is recommended by NICE and the Department of Health as the best practice model for end-of-life care, and it is designed to improve the care of the patient in the last hours or days of life.

Last year numerous media stories claimed elderly patients had been refused food and water to speed up death and that neither they, nor relatives have been told doctors consider their case to be terminal. Trusts were accused of being incentivised to put elderly patients on the pathway to cut costs.

In response to the attention, earlier this year the DH announced that former Kings Fund chief-executive Baroness Julie Neuberger would chair a review to examine the LCP, which will publish its findings this summer.

As part of its written response to the review, the RCGP said that while some GPs said the LCP was useful in giving GPs a framework for prescribing, and was useful for newly qualified GPs, who may need more guidance on how to deliver palliative care, many said the volume of paperwork associated with the pathway and the negative publicity surrounding it meant they avoided using it.

The response document said: ‘Some GPs said that they used the principles of the LCP - and found these helpful - but did not use the pathway itself. Respondents mentioned both the volume of paperwork associated with the LCP, and the recent adverse publicity surrounding the pathway as reasons for not using the LCP itself.’

It added: ‘A problem with implementation of the LCP flagged by some GPs focused on the negative publicity that the LCP has received recently. Respondents felt that use of the LCP can cause additional concern amongst relatives, who may feel that their loved ones are being condemned to a standardised ‘model of dying’.

‘One GP said: “More recently [the LCP] can be a barrier, rather than a tool to aid communication and planning for a dignified death.”

Some GPs felt the word ‘pathway’ did not aid communication with relatives and patients, as pathway suggests a standardised approach to care. They advocated re-naming the LCP as ‘best practice’ or ‘guidelines’, the response said.

GPs also suggested there should be tighter guidelines around the use of provision of IV fluids within the LCP as this was a source of concern for patients, better communication by healthcare professionals about how patients can come off the pathway if necessary, as well as improved communication between primary and secondary care.

In their response to the review, the BMA’s Medical Ethics committee said it ‘strongly supports’ appropriate use of recognised frameworks for end of life care such as the LCP, and will ‘continue to discuss and monitor’ the pathway.

Readers' comments (15)

  • The pathway is fine, the issue is increasing requests for Doctors to "write it up in case" in advance of the patient entry to the phase of illness where it is appropriate.
    In Liverpool, "Liverpool Community Health" the community nursing trust solicit completion for every patient "at the end of life" the definition they use is last year of life.Decline and your patient can be alive 18 months later, I only started declining when I realised no one was lasting 6 months, massive "turn for the worse" after surgery closed on a Friday and dead on the pathway by Monday.

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  • Yep, absolutely correct

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  • I think the RCGP have got this the wrong way round.
    GPs have stopped ( or never started using) the LCP because
    1. it implies a one size fits all programme leading to certain death without individual choice.
    2. The people using it can sometimes follow it to the letter and do not show flexibility leading to 1.
    3. There is a feeling amongst some GPs that incentivising us to put people on the pathway with a "target number" is inappropriate and insensitive.
    4. It can be difficult to be sure that someone is in the last 6-12 months of life, but puttting them on the "pathway" makes it a certainty which will be acted on. A "path" leads to a destination.

    Despite this, it can be a useful guide for those who are inexperienced or lack the experience to provide the best care;.

    It is these genuine concerns which have caused the press reaction, not GPs being influenced by the press.

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  • If you put a dog on the LCP you would quite rightly be found guilty of causing unnecessary suffering, and prosecuted for it. Bring back the 'Brompton's cocktail' - if ever there was a legitimate use for cocaine, then 'end of life' is surely it.

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  • I agree with Alison Lloyd's comment about the fostering of a 'one-size-fits-all' mentality that the LCP encourages. I also think that bad publicity has had a hand in discouraging its use.
    It is perfectly possible to manage the palliative needs of the patient well without, and to do it badly with, the LCP.

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  • Vinci Ho

    (1) Like I said in the readers' comments on 'LMC fighting back on publicity' article today , we cannot run away from public opinions on what we are doing these days, whether you like it or not. Question is only whether we have done enough to re-educate and shift opinions.
    (2) I remember when we had a debate in Liverpool LMC about LCP last and this year , we conceded that perhaps we should not use the name LCP even we are to use the pathway
    (3) The principles of LCP are correct and in fact reflecting what GPs have been doing in terminal care for many years in this country. Problem is at the level of implementing with good , consistent and progressive communications with family , patient and the carers. More than less are required to help them to see through a difficult time of life. As the patient's condition continues to worsen , further communications and reassurances to ensure all parties work under the same principle and understanding . Time spent is a determining factor of success .
    (4) The danger with this current climate with austerity is put the label of LCP down with little follow ups. I think LCP controversy has just epitomised the requirement of more manpower and expertise in the frontline to deliver a good principle based care pathway .......

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  • Surely placing a patient on the pathway is only appropriate when said patient is no longer capable of taking oral medication and has clearly entered the last few days of life? I would be very unhappy about writing up the pathway forms until this time on a 'just in case' basis. If the relatives are kept informed at all times and the patient is reviewed regularly, there should not be any problems. I cannot be the only one to have taken patients off the pathway if they unexpectedly pick up.

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  • Vinci Ho

    Yes , interesting.
    Although it is uncommon to reverse the decision and take people off the pathway , one should not live on the presumption that LCP or in fact any end of life care pathway , is IRREVERSIBLE .

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  • LCP is by definition a death sentence and worse, it gives non doctors the authority to start the process. I find it scary and will nearly always refuse to "implement it" preferring to individualise the care based on the ever changing needs of the patient.

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  • I use the discuss with relatives and common sense pathway

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