Letters Liverpool care pathway

How do we make the Liverpool care pathway’s laudable aspirations reality?

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7634 (Published 13 November 2012) Cite this as: BMJ 2012;345:e7634
  1. Eileen Palmer, palliative medicine consultant1
  1. 1Hospice at Home West Cumbria, Workington Community Hospital, Workington CA14 2RW, UK
  1. eileen.palmer{at}doctors.org.uk

Some concerns about the Liverpool care pathway expressed in recent newspaper articles are sadly true,1 2 but Spence gives the other side of the story.3

Life is uncertain. Death is rarely 100% predictable, even by the best doctors. Dying can be much more difficult—physically and emotionally—than we would wish. Undertreatment and overtreatment in the last days of life can compound distress. Communication around dying and all its uncertainties often falls short of the ideal. Despite this, most people want their death to be as good as is possible.

These were exactly the reasons that the Liverpool care pathway was born. Although imperfect, it remains the only tool that takes doctors and nurses systematically through basic principles of “comfort care” for patients in the last day or two of life. The pathway recognises the uncertainty of dying and has safeguards, including a requirement on the “entry” page for a full multidisciplinary team review should any concerns be raised about the management plan by the patient, relatives, or any team member.4

The first three goals of the pathway are all about communication, firstly with patients, then with relatives. Goal 3 specifically asks staff to ensure that patients and relatives have the opportunity to discuss what matters most to them.

These basic steps precede goals such as ensuring access to pain relief and other comfort drugs or interventions. Nowhere are overdoses of drugs or the routine withdrawal of hydration or nutrition condoned. The pathway recommends cautious drug doses, only if needed, and careful multidisciplinary review of invasive treatments, including drips and feeding tubes, with full explanation to the family of any decisions made to enhance the dying person’s comfort.

These are laudable aspirations. How do we make them reality?


Cite this as: BMJ 2012;345:e7634


  • Competing interests: None declared.