Letters Palliative care beyond cancer

Good death for all remains distant goal

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5815 (Published 19 October 2010) Cite this as: BMJ 2010;341:c5815
  1. R J Clearkin, physician1
  1. 1Market Harborough, Leicestershire LE16 8EL, UK
  1. rjemc{at}lineone.net

Ellershaw and colleagues again defend their Liverpool care pathway.1 The pathway has obvious appeal, but it has proved controversial, and reports of misuse remain disturbingly frequent.2

Despite decades of research in the care of patients with cancer, the accurate prediction of dying—the last 48 hours of life—remains difficult.3 Accuracy is obviously important to patients and their next of kin. Surprisingly, Ellershaw and colleagues imply that the lack of data supporting accurate prediction of dying in the 70% of deaths not due to malignancy is of no significance. They also imply that evidence of the pathway’s widespread use obviates the need for evidence that its use is safe and appropriately timed.

They briefly mention three areas of practice with the pathway that have been identified in national audits as being in need of improvement. However, to describe communication as merely needing improvement is akin to describing bankruptcy as a minor cash flow problem. Both audits show that most patients on the Liverpool care pathway do not know that they are dying, and only around half know their diagnosis.4 5 The results for meeting spiritual and religious needs are even worse. These failures are not simply medically anachronistic: they are dishonest and inhumane.

Indifference to the need for accurate diagnosis of dying and to the most basic needs of patients and next of kin goes deeper than a simple lack of education and suggests fundamental flaws in the approach adopted by the Liverpool care pathway project. Achieving a good death for all remains a distant goal.


Cite this as: BMJ 2010;341:c5815


  • Competing interests: None declared.


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