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Liverpool Care Pathway written off too soon, says senior ethicist

The scrapping of the Liverpool Care Pathway was premature and it should be brought back, a senior ethicist has argued.

In a paper published in the Medical Ethics Journal, Dr Anthony Wrigley, from the Centre for Professional Ethics at Keele University, said the main problem with the end-of-life care pathway was not the recommendations contained but failure in implementation.

The Government put a stop to it last year in line with a recommendation from the independent review led by former Kings Fund chief executive Baroness Julie Neuberger that it should be phased out within one year.

Baroness Neuberger’s review was set up by the DH in 2012, amid media reports that 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.

But Dr Wrigley’s paper says the concerns raised in the Neuberger review were ‘largely based either on misconceptions about or improper implementation’ of the pathway.

The paper said: ‘This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered or poor incidences of practice by the review is of genuine concern for end-of-life care, the inferences drawn from this evidence are inconsistent with the causes for concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high-quality care 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.’

Speaking to Pulse, Dr Wrigley said: ‘My concern is that we are throwing the baby out with the bathwater.’

‘It seems Liverpool Care Pathway is widely regarded as the best end-of-life care guidance that we have in the world, and the report did not offer any alternative. So not only did it not give reasons what was wrong with it, it also failed to give any substantive case for what we should adopt in its stead.’

‘Now there is no country-wide guidance. There are areas that have their own guidance, but actually what I am told is that they are implementing aspects of the Liverpool Care Pathway simply because there is nothing better to replace it with. They are not calling it that, because obviously there is a lot of tension attached to that name.’

He added: ‘What do I hope would happen next? I hope that there will be recognition of the fact that we should reintroduce the Liverpool Care Pathway. There is tension with that name, but there is no need to abandon good practice. We should readopt everything that was good with it, it is an ongoing guidance document anyway. I would also like to see better end-of-life care training within general palliative care. People need better training on how the guidance should be implemented and on general ethical decision making.’

GPs, and the BMA, had remained in favour of the care pathway but had been less likely to put people on it following adverse publicity, the RCGP found last year. At the same time, a Pulse survey revealed that one in five GPs had reported an increase in patients’ concerns about the care pathway.

Click here to read the full paper

Readers' comments (2)

  • Vinci Ho

    At the end of the day , any pathway for terminal care is about spending time to communicate continuously with all parties involved in the care of the dying patient ( medical and nursing staff , all relatives and patient oneself) . Circumstances change throughout the last hours of life and people from all parties need updating and reassurance so that everyone agrees to the plan or pathway . LCP is only a name but requires experiences and hence training in dealing with these terminal situations. In addition , the diagnosis of 'dying' can be tricky and governs the 'right' timing if implementing any of these pathways .

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  • Dr Mustapha Tahir

    The LCP was greatly misunderstood. No training, and the right publicity, to health care workers and patients were undertaken prior to introduction. Not until The Daily Mail and the likes of it got hold of it!
    Mustapha Tahir

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