Feature Data Briefing

The Liverpool care pathway: what do specialists think?

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1184 (Published 01 March 2013) Cite this as: BMJ 2013;346:f1184

Re: The Liverpool care pathway: what do specialists think?

The LCP is not safe

The data briefing on the LCP (1) sets out rather well some very good reasons why the LCP is unsafe for use in standard clinical settings.

Firstly, there is a real need to question the LCP’s clear statement that treatment decisions can be reliably based upon prognosis. We know that prognosis is hard to establish (2), and that it is harder to establish among non- cancer people who are dying than it is among those with cancer. The survey suggests that non specialists are more confident than they should be in their ability to diagnose dying. While only 72% of specialists in palliative care thought that doctors and nurses were able to judge when a patient is dying, a much larger 92% of non specialists thought that they could. That must surely be a cause for concern. The LCP is fully based upon a decision that someone is dying within the next 72 hours and prompts treatment decisions that depend upon the reliability of that diagnosis. And yet, in general clinical settings where prediction of prognosis is often more difficult, non- specialists are more confident than specialists working in palliative care.

Perhaps of even greater concern is that a huge majority of doctors surveyed said they would want to be placed upon the LCP if they had a terminal illness. We all know that terminal illness last for weeks and months, and yet, respondents to a simple question simply state that they would want to be on the LCP in such situations. As stated in the article the terminally ill may or may not be dying. If clinicians would want to be on the LCP if they were terminally ill (not necessarily dying) and the authors of this report managed to pose such a question, then surely this study shows the deep misunderstandings which surround the LCP.

The LCP sets out clearly that all patients placed upon it should be prescribed opiates, sedatives and anti-secretory drugs (at least on an as required basis as required) while also requiring a review of nutrition and hydration in all patients. The national LCP audit [3] shows very high compliance with prescribing these drugs (99% for opiates and 96% compliance for other medications that sedate etc). The national audit also shows that only a tiny number of people on the LCP are started on fluids. The combination of sedative medication and dehydration can easily be lethal if the diagnosis of dying is wrong. Placing those simple facts alongside what we know about the unreliability of diagnosing dying it should surprise no one that relatives have been so upset about the LCP.

We are repeatedly told that the LCP is safe and does not kill, but that misuse and poor training (i.e. are the problem. It is clear from this study that the LCP appears to give non specialists in particular a false confidence in their ability to diagnose dying alongside clear guidelines as to what they should do once they have (unreliably) diagnosed dying. And many of the actions set out as good practice may then cause death at least among those who are wrongly diagnosed.

It is also of interest that 50% of deaths in mid staffs were on the LCP (4). While there is no published evidence that any of those deaths were linked to the LCP, which was only implemented at Mid Staffs at the end of the period in question, it must be clear that when the LCP is used more widely, there will be more patients prescribed medicines whose inappropriate use will cause death. And having required medicines to be written up on an as required basis, the decision to administer can be taken by the most junior doctor or nurse who is working on a shift with no prior knowledge of the patient.

I personally find it hard to believe doctors whose care of patients on the LCP has led to serious complaints are necessarily poor clinicians. Rather, good doctors have done what they were told is good practice and placed people on the LCP whose guidance they follow. And this study shows that doctors have an extraordinary confidence in the LCP which encourages them to believe that they can diagnose dying. That is in direct contrast to the many complaints and negative publicity about it. The LCP is said to be a quality improvement tool. I am sure that it has had a significant effect upon UK medical practice, but have to contend that a substantial part of that effect has been very harmful.

I no longer think that the LCP is a good pathway which is misused. Rather it is a dangerous pathway that is prone to failure and which can, of itself therefore, cause death. It is teaching doctors to think that they can reliably diagnoses imminent dying when , in truth, we know they cannot. And then, with good practice dictating the almost universal prescriptions of opiates and sedatives to those on the LCP [3], doctors find that those whom they diagnose as dying do indeed die pretty quickly.

Care of the dying requires the highest standards of individualised holistic care with good alleviation of symptoms of those who are dying. The LCP simply does not appear to do that. The complaints about the LCP should be no surprise.

References

1 BMJ 2013:346, 1184

2 Pullicino P. The dangers of abandonment of evidence-based medicine in the use of the Liverpool Care Pathway. Catholic Medical Quarterly Volume 62(4) November 2012 http://www.cmq.org.uk/CMQ/2012/Nov/LCP-Pullicino.html

3 National care of the dying audit- hospitals. Round 3 Generic audit 2011-2. http://www.liv.ac.uk/media/livacuk/mcpcil/documents/NCDAH-GENERIC-REPORT...

4 Daily Telegraph, 15th Feb 2013 Up to 50pc of deaths at Mid-Staffs NHS trust on Care Pathway http://www.telegraph.co.uk/health/healthnews/9871169/Up-to-50pc-of-death...

Competing interests: No competing interests

06 March 2013
Adrian J Treloar
Consultant Old Age Psychiatrist
Bexleyheath Centre
Bexleyheath, London