The Liverpool care pathway: what do specialists think?BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1184 (Published 01 March 2013) Cite this as: BMJ 2013;346:f1184
Thirty years ago, a nurse observed the care given to 50 dying patients across four large hospitals. She documented poor oral hygiene, lack of assistance with eating, unquenched thirst, and increasing isolation of patients towards the time of death.1
Then as now, most people in England died in hospital. To improve care for some of the hundreds of thousands of people in hospital during their final hours and days of life, end of life care pathways were introduced.2 The Liverpool care pathway is the most widely used integrated care pathway, but others have been developed.3 However, the Liverpool care pathway has recently received sustained media criticism in the UK,4 resulting in two ongoing reviews by the Department of Health and the NHS National End of Life Care Programme.5 6
In February, in conjunction with Channel 4’s Dispatches, the BMJ emailed 3021 UK hospital doctors for an anonymous online survey of their views on the Liverpool care pathway. Out of 647 respondents (response rate 21%), 563 doctors had used the pathway in clinical practice, and these 563 were enrolled in the full survey. They comprised 185 palliative medicine consultants (roughly 40% of the UK total), 168 doctors in training or career grade posts in palliative medicine, and 210 doctors in other specialties but with some experience in palliative medicine. The response rate is similar to that in other online surveys of doctors, but non-response bias is possible.7
Overall, 57% (321/563) of the doctors thought that recent negative press coverage had led to the Liverpool care pathway being used less (fig 1⇓). This rose to 74% (136) for palliative medicine consultants, supporting concerns made by leaders in the specialty.8 Among those doctors who said there was less use of the pathway, 60% (194) said patients and relatives had asked them not to use it and 80% (258) said staff were apprehensive about relatives’ complaints. One palliative medicine doctor said, “Negative press regarding LCP [the pathway] has caused additional distress for relatives at an already distressing time when their loved one is dying. This has caused a dilemma in judging if discussing the LCP will cause more distress than the benefit of being on the LCP for coordination of care in the dying phase.”
Another specialist said: “Often where families have been against the use of the LCP because of the negative press, they have been in agreement with application of its principles.”
One accusation in the press has been that the pathway has been used in patients “to save money” and that “patients are being dispatched via the LCP because—simply and crudely—the hospitals need their beds to meet overwhelming demand.”9
In their experience, 98% (550) of respondents did not think that pressure on beds or other resources had influenced decisions to use the pathway for end of life care. One trainee thought that staffing pressures had in fact decreased use of the pathway and said, “High levels of staffing are required to implement it properly. Doctors must have the time and training to communicate with families, and the proper implementation of the LCP requires highly trained nurses.”
However, one consultant had heard of “pressure exerted in some areas to get the numbers up so that the hospitals do not fail to reach their CQUIN [Commissioning for Quality and Innovation] targets.”
Local commissioners in England use CQUIN payments to improve service by linking up to 2.5% of NHS providers’ income, a total of roughly £700m (€800m; $1100m), to performance targets.10 Of this, between £20m and £30m is for targets related to the use of the Liverpool care pathway,11 as advocated by the Department of Health’s end of life care strategy and by a National Institute for Health and Clinical Excellence (NICE) quality standard.12 Targets may range from ensuring “that a meaningful conversation with a patient admitted at the end of life is recorded in a meaningful way and takes into account previous care planning”13 to “50% of patients who die in hospital (expected deaths) should die on a Liverpool care pathway.”14
Only 13% (75) of respondents agreed that hospitals should be offered financial incentives for using the pathway, with 58% (325) disagreeing. One said, “Setting targets for the use of a tool that was intended simply to ensure best practice was never wise and always open to misinterpretation,” and another suggested that a better financial reward would be for achieving a set “percentage of ward based nurses and doctors who have completed training in the use of the pathway.”
Bee Wee, president of the Association for Palliative Medicine, also highlighted lack of training: “We know that there are some hospitals where the Liverpool care pathway is introduced, there is very little training of the staff, there is nobody who is going around making sure that it is used correctly.”15
In the survey, 92% (194) of doctors in non-palliative medicine specialties thought that doctors and nurses were able to judge when a patient is dying, but only 78% (145) of palliative medicine consultants agreed. Recognition of a dying patient and communication of this to patients and relatives were highlighted as particular training needs. One consultant said “There are undoubtedly cases reported in the press where end of life care has not been managed well. These should be criticisms of training, assessment and common sense. They are not correctly directed at the pathway. It is as irresponsible as banning insulin because of the damage and deaths that have occurred over the years due to inappropriate, inaccurate or malicious use of this drug.”
Regarding the Liverpool care pathway itself, 91% (514) thought that it represented best practice for care of the dying patient, including 89% (164) of palliative medicine consultants. If used properly, 98% (551) thought that it allowed patients to die with dignity, with two respondents disagreeing (0.4%) (fig 2⇓).
When asked if they would want the pathway during a terminal illness, 90% (509) said yes and 3% (16) said no (fig 3⇓). Some respondents pointed out, entirely correctly, that it was not clear whether the question meant dying from a terminal illness. We are sorry for this. Dying patients may or may not have terminal illnesses; the terminally ill may or may not be dying. Other damaging misconceptions, according to specialists, were that the pathway 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.
One doctor said that this “scaremongering” was “putting end of life care back about twenty years, where dying patients were hidden inside rooms and not seen by a consultant.”
It was also about 20 years ago that Mina Mills and colleagues published their observations of 50 dying patients in hospitals in the BMJ and declared that “Our findings show the desperate need for improvements in the care of dying patients.”16
Now as then, doctors should use the opportunity to promote further education, training, and improvements in the care of dying patients.
Cite this as: BMJ 2013;346:f1184
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.