Re: The Liverpool care pathway: what do specialists think?
We are grateful to Krishna Chinthapalli for the article ’'The Liverpool Care Pathway: what do specialists think?' since it is important to have a balanced debate on the use of the Liverpool Care Pathway (LCP) in end-of-life (EOL) care. Recent negative press coverage has indeed had an impact on EOL care: in University Hospitals Bristol NHS Trust the use of our EOL tool (not the LCP) dropped to 37% in patients dying in December 2012 compared to 67% in December 2011 (see below).
We agree that the principles of the LCP are essential in improving the care given to the dying, but argue this can only really be achieved if healthcare professionals in acute hospitals are willing or allowed to consider that a patient might be dying. In Chinthapalli's report 92% of non-palliative medicine doctors (but with experience in palliative medicine) and 78% of palliative medicine consultants thought that doctors and nurses were able to judge when a patient is dying. It would be interesting to know what hospital clinicians without experience in palliative medicine think (and if this group were over-represented amongst the non-responders) since we know that the diagnosis of dying is made very close to death in the majority of patients(1) explaining why the average time a person spends on the LCP is only 29 hours.(2)
Findings from our mixed methods study which explored the impact of a brief end-of-life care tool on the care given to dying patients in the acute hospital setting add helpful insights to this report.(3) During our interviews with a range of doctors and nurses a culture where it required ‘bravery’ to acknowledge a patient might be dying was described.(4) Interviews with newly qualified doctors have echoed this.(5) If our findings resonate with other acute hospitals, then it might explain why a ‘good idea’ based on best practice has perhaps not always translated into ‘good care’. The proposed training in the recognition of the dying patient and communication about this to patients and relatives will help, but only if an attempt is made to alter attitudes also.
If acute care settings continue to ignore this culture, the care of dying patients is unlikely to improve. We need to be 'brave' enough to address this so that care can improve for all whose deaths should be anticipated.
J Gibbins, R McCoubrie, K Forbes, C Reid
1. Gibbins J, McCoubrie R, Alexander N, Kinzel C, Forbes K. Diagnosing dying in the acute hospital: are we too late? Clinical Medicine 2009;4:116-19
2. National Care of the Dying Audit - Hospitals (NCDAH) Round 3 Generic Report 2011/2012. 2012. 9-7-2012. Ref Type: Online Source
3. Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie Rachel, Forbes K. BMJ Support Palliat Care doi:10.1136/bmjspcare-2012-000322 [Epub ahead of print]
4. Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie Rachel, Forbes K. Healthcare professionals’ perspectives on delivering end of life care within acute hospital trusts: a qualitative study. Under review BMJ Supportive and Palliative Care
5. Gibbins J, McCoubrie R, Forbes K. Why are newly qualified doctors unprepared to care for patients at the end of life? Med Educ 2011;45(4):389-99
Competing interests:
No competing interests
06 March 2013
Jane Gibbins
Consultant in Palliative Medicine
Rachel McCoubrie, Karen Forbes, Colette Reid
Cornwall Hospice Care
St Julia’s Hospice, Foundry Hill, Hayle, Cornwall, TR27 4JA
Rapid Response:
Re: The Liverpool care pathway: what do specialists think?
We are grateful to Krishna Chinthapalli for the article ’'The Liverpool Care Pathway: what do specialists think?' since it is important to have a balanced debate on the use of the Liverpool Care Pathway (LCP) in end-of-life (EOL) care. Recent negative press coverage has indeed had an impact on EOL care: in University Hospitals Bristol NHS Trust the use of our EOL tool (not the LCP) dropped to 37% in patients dying in December 2012 compared to 67% in December 2011 (see below).
We agree that the principles of the LCP are essential in improving the care given to the dying, but argue this can only really be achieved if healthcare professionals in acute hospitals are willing or allowed to consider that a patient might be dying. In Chinthapalli's report 92% of non-palliative medicine doctors (but with experience in palliative medicine) and 78% of palliative medicine consultants thought that doctors and nurses were able to judge when a patient is dying. It would be interesting to know what hospital clinicians without experience in palliative medicine think (and if this group were over-represented amongst the non-responders) since we know that the diagnosis of dying is made very close to death in the majority of patients(1) explaining why the average time a person spends on the LCP is only 29 hours.(2)
Findings from our mixed methods study which explored the impact of a brief end-of-life care tool on the care given to dying patients in the acute hospital setting add helpful insights to this report.(3) During our interviews with a range of doctors and nurses a culture where it required ‘bravery’ to acknowledge a patient might be dying was described.(4) Interviews with newly qualified doctors have echoed this.(5) If our findings resonate with other acute hospitals, then it might explain why a ‘good idea’ based on best practice has perhaps not always translated into ‘good care’. The proposed training in the recognition of the dying patient and communication about this to patients and relatives will help, but only if an attempt is made to alter attitudes also.
If acute care settings continue to ignore this culture, the care of dying patients is unlikely to improve. We need to be 'brave' enough to address this so that care can improve for all whose deaths should be anticipated.
J Gibbins, R McCoubrie, K Forbes, C Reid
1. Gibbins J, McCoubrie R, Alexander N, Kinzel C, Forbes K. Diagnosing dying in the acute hospital: are we too late? Clinical Medicine 2009;4:116-19
2. National Care of the Dying Audit - Hospitals (NCDAH) Round 3 Generic Report 2011/2012. 2012. 9-7-2012. Ref Type: Online Source
3. Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie Rachel, Forbes K. BMJ Support Palliat Care doi:10.1136/bmjspcare-2012-000322 [Epub ahead of print]
4. Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie Rachel, Forbes K. Healthcare professionals’ perspectives on delivering end of life care within acute hospital trusts: a qualitative study. Under review BMJ Supportive and Palliative Care
5. Gibbins J, McCoubrie R, Forbes K. Why are newly qualified doctors unprepared to care for patients at the end of life? Med Educ 2011;45(4):389-99
Competing interests: No competing interests