Posted by: GPs To Be11 September 2013
The findings of the government-commissioned review into The Liverpool Care Pathway make me want to weep. It’s not that I necessarily disagree with everything that they have said but it makes me saddened to see the hard work of many reduced to a collection of anecdotes and Daily Mail opinion pieces.
Before I switched to GP training I was a registrar in palliative medicine and I saw how much education was poured into the LCP, how much time was spent auditing its performance and how much support was made available to those using the document in different settings. I acknowledge that it wasn’t perfect and its interpretation by health care professionals wasn’t always correct, but I think it allowed non-specialists to deliver excellent quality end of life care with confidence and clarity and I fear its phased withdrawal might leave us with a much more dangerous situation.
Firstly, I feel I need to clear something up once and for all: the LCP does NOT encourage the withdrawal of food and fluids. The natural reduction in appetite and thirst which accompany the dying process can be one of the most difficult things for a patient’s family to reconcile. The act of preparing food and feeding someone can be one of the only practical things that relatives can do for someone so ill and the loss of this nurturing role can be very upsetting. This, however, does not mean that inserting an IV cannula or NG tube is the right thing to do either clinically or ethically. Each patient needs to have their requirement for artificial nutrition and hydration reviewed on a regular basis, something the LCP paperwork demanded.
I think the main source of discontent around the LCP has been failed communication, as with so many of the complaints received by the NHS. When used well, the LCP triggered a diagnosis of ‘dying’ and in turn sensitive discussions with patients and their loved ones about what to expect and an exploration of their feelings and wishes for the dying process. Of course, as with any diagnosis, we don’t always get it right which is why the LCP imposed regular reviews and patients could be taken off as well as started on the pathway. It is not fair of the general public to demand us to be always right. People are individuals and they all behave completely differently in death as well as in life.
The review found that ‘communication was very poor and medical staff sometimes dodged painful discussions with patients and families’ which is depressing and unsurprising in equal measure. Death is hard to face for everyone which is probably why we’re not very good at talking about it. Unfortunately it is a rather vital part of our job so perhaps we all need to man up a bit and start tackling it head on. Perhaps we need more training in communication around the end of life, perhaps we need more experience, maybe we need to accept that we’re all human, death is hard, but we’ll do our best. And by ‘everyone’ I mean patients, families, doctors, nurses and The Daily Mail.
Dr Laura O’Loghlen is a GPST1 who lives in Cheltenham and works in Gloucestershire