Liverpool care pathway review shows challenges in palliative care

The law of unintended consequences can be insidious. The Liverpool care pathway (LCP) has been encouraged over the last decade with the express objective of avoiding unnecessary interventions in the care of people who are clearly dying, and ensuring they achieve a good death. However, it should now be phased out and replaced by an individual end-of-life care plan, according to the findings of the independent review led by Lady Julia Neuberger.

Almost a decade ago, the House of Commons health select committee conducted an inquiry into palliative care and while it supported the take up of tools such as the Gold Standards Framework and the LCP, the committee cautioned "that there are significant challenges in raising the skills and awareness of all healthcare staff in palliative care." The findings of the independent review provide testimony to the continued failures of training around the LCP, with the result that far from providing a model of good practice in palliative care, the LCP too often leads to poor practice - "uncaring, rushed and ignorant".

This is a shocking indictment of the care of people in their final days of life, often very elderly people whose relatives were left with the impression that their life was no longer valued. Withholding food and drink has caused the greatest concern and distress with staff apparently on occasion refusing to allow liquids for people who were thirsty and dehydrated. The review is in no doubt that the failure to provide oral hydration and nutrition "when still possible and desired should be regarded as professional misconduct."

Poor communication with patients and relatives is at the root of many of the failures and criticisms of the LCP, and evidence to the review found significant numbers did not feel involved in discussions about the care plan, or were not given the chance to be involved. People are sometimes not told that a loved one is dying or what they can expect to happen.

Inappropriate use of opiate pain killers and tranquillisers was also the focus of criticism, particularly when this led to a patient becoming drowsy, and relatives left wondering if the use of drugs had hastened death.

The review has recommended that the LCP should be phased out, and this has been accepted by health minister Norman Lamb. However, it is vital not to abandon the core principles which underpin the model. The failure of the LCP has been in its application and poor support; the review found that when used appropriately "patients die a peaceful and dignified death", but that implementation is sometimes associated with poor care.

The clear thinking and pithy recommendations of this review will be welcomed, so too will the speed of response from government. It is clear that when the LCP is operated "by well trained, well-resourced and sensitive clinical teams, it works well." The reverse is also true and the need for new guidance and training for all staff is evident. Nonetheless, existing guidance is not being adequately followed or understood and major cultural change is needed at all levels of health and care to prioritise good quality end-of-life care. The review identifies the need for a strategic approach from NHS England down to clinical commissioning groups, and with the Care Quality Commission taking a lead in reviewing how well dying patients are treated.

It is distressing that what began as a model to raise the quality of care for the dying has too often been reduced to a tick box procedure which takes insufficient account of individual needs or wishes, and where vital care and compassion are absent. It is a tragedy however for families and carers who have lost relatives who have been cared for under the LCP, and for whom there will remain considerable distress and unanswered questions. Did their relative die a hastened death? Did they suffer unnecessarily because of the interpretation of the LCP? Andwould they actually have been able to live longer and die better without the involvement of the LCP?

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.