'Liverpool care pathway' criticism causing damage, say doctors

1 March 2013

Nine out of 10 senior doctors would choose Liverpool care pathway for themselves

The Liverpool care pathway: what do specialists think?

The overwhelming majority (90%) of senior palliative care doctors who responded to a survey carried out for Channel 4’s Dispatches and the BMJ think the Liverpool care pathway (LCP) is the right approach for caring for patients in their final hours, and they would choose it for themselves.

However, almost three quarters (74%) think that recent criticism in the media and elsewhere has led to less use of the LCP. Of these, 60% said patients and relatives had asked them not to use it and 80% said staff were apprehensive about relatives’ complaints.
The results, published on bmj.com today – and due to be aired on Channel 4 Dispatches on Monday 4 March – support concerns already made by palliative medicine leaders.

One specialist said the controversy around the LCP “has caused additional distress for relatives at an already distressing time when their loved one is dying.” Another said that that it was “putting end of life care back about twenty years, where dying patients were hidden inside rooms and not seen by a consultant.”

The Liverpool care pathway was introduced to help doctors and nurses provide quality care for patients during their final hours and days of life, but it has recently been criticised after accounts of patients having food and fluids withdrawn and the use of financial incentives. Some families are claiming that their relatives could, and should, have lived longer.

As a result, the Department of Health and the NHS National End of Life Care Programme are currently reviewing the pathway.

In February, in conjunction with Channel 4 Dispatches, the BMJ emailed 3,021 hospital doctors for an anonymous online survey of the Liverpool care pathway. The results are based on answers from 563 doctors who responded and had used the pathway in their practice (185 palliative medicine consultants, 168 in other grades in palliative medicine, and 210 doctors in another specialty). The respondents included about 40% of all palliative medicine consultants in the UK.

Overall, 91% (514) thought that the pathway represented best practice for care of the dying patient, including 89% (164) palliative care specialists. If used properly, 98% (551) thought it allowed patients to die with dignity, with only two respondents (0.4%) disagreeing.

When asked if they would want the pathway during a terminal illness, 90% (509) said yes and 3% (16) said no. And despite media reports, almost all (98%) did not think that pressure on beds or other resources had influenced decisions to use the pathway.

However, only 13% (75) respondents agreed that hospitals should be offered financial incentives for using the pathway, with over half (58%) disagreeing.

Concerns about lack of training in the use of the pathway were also raised, in particular around recognising a dying patient and communicating this to patients and relatives.

Other respondents pointed to “damaging misconceptions” about the pathway, such as it precludes nutrition, hydration or antibiotics, that it is a one way process with no further patient review, and that it is an active intervention to hasten death.

Dr Fiona Godlee, BMJ Editor in Chief, said: “This survey gives overwhelming support for the LCP from doctors who have experience in using the pathway when caring for patients in the last few days of life. The fact that most of these doctors said they would choose the LCP for themselves is doubly reassuring. The recent adverse media coverage of the LCP has been misleading and has damaged patient care. I hope this survey goes some way to restoring public confidence in the LCP as a reasonable and compassionate choice for patients and their families when making decisions about end of life care.”

Death on the Wards: Channel 4 Dispatches  (Monday 4 March, 8pm) interviews leading specialists, terminally ill patients and families to explore the simple question at the heart of this controversy: can doctors accurately tell when someone is dying? 

 

www.channel4.com/dispatches