Intended for healthcare professionals

Views & Reviews From the Frontline

How the Liverpool care pathway has transformed end of life care

BMJ 2012; 345 doi: (Published 31 October 2012) Cite this as: BMJ 2012;345:e7308
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

The media have criticised the end of life Liverpool care pathway (LCP), implying it a deliberate attempt to end life prematurely to free hospital beds.1 Reports say that general practitioners are establishing “death lists” of patients to put on the pathway.2 Several distressing stories from families support these claims. Naturally doctors are angered by these accusations. And there is another side to the story.

Twenty five years ago doctors received no training in end of life care. The most junior doctors provided care in the most chaotic way. I wasn’t able to recognise death. Patients were enduring hopeless interventions and resuscitation because I was trained to “do something.” I had no experience in pain relief. In hospitals far from their loved ones, patients were left screaming in pain in the dark, and behind unmarked curtains were undignified and peace-less deaths. Those in command seemed blind to the carnage. Patients and families were always unprepared for the inevitable deaths. As a 23 year old, I was expected to give comfort and explanation, but I lacked the skills and maturity to offer either. Anger and resentment was the norm. My inexperience and lack of insight offered me protection at the time but no comfort over time.

I vowed to do differently and wanted to provide palliative care in patients’ homes. I learnt how to give proper pain relief and tried to talk openly about dying. But generally we ran scared of death, and still we gave patients unhelpful unrealistic hope. Out of hours doctors and different nursing shifts broke continuity of care. Patients were admitted to hospital without their consent—because it is always easier to do than not to do. Care was disorganised and poor.

But in recent years care has improved. The Liverpool care pathway and committed district nursing teams are transforming care. We talk about death in an open way and decide where patients die. Used properly with senior supervision, the pathway offers structure to a peaceful, pain-free, dignified death at home—a good death. The “death lists” exist to tackle a taboo: they facilitate discussion about death with patients and families. But the newspapers are right: this pathway must be used with full explanation and the consent of all involved. If it has not been used in this way, then a review is welcome if only to reassure the public.3 Lastly, the media should reflect on this: there were no good old days in end of life care, and so we need the Liverpool care pathway.


Cite this as: BMJ 2012;345:e7308



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