Intended for healthcare professionals

Rapid response to:

Practice Competent Novice

Caring for a dying patient in hospital

BMJ 2013; 346 doi: (Published 17 April 2013) Cite this as: BMJ 2013;346:f2174

Rapid Response:

Sir, We read this interesting, informative and useful paper by Sleeman and Collis. Although the Liverpool Care Pathway ( LCP ) (1) is now defunct, the algorithm on pain management with opioid drugs shown in Figure 2 contains multiple errors for which the authors are not responsible. The first question in the algorithm “Is the patient in pain?” can only have a “Yes” or “No” answer. A response such as another question “Is the patient on an oral opioid?” is not a logical answer. The decision-making logic also needs two questions to be asked, only one of which is described in the original algorithm. The faulty algorithm can be traced to page 2 of a document on LCP Supporting Information giving Medication Guidance Examples published by the Marie Curie Palliative Care Institute in Liverpool (2).

We have redesigned the algorithm (Figure 2) according to the British Standard BSI 4058 for flow charts (3) and we have found a logically correct and very similar algorithm in Version 11 ( 2008 ) of the LCP used by York and North Yorkshire NHS Mental Health Trust Community and Mental Health Services (4) after producing our own.

The 12th and final version of the LCP (1) does not contain any drug management algorithms and suggests that local NHS Trust users are responsible for these according to their local medicines management and palliative care policies. Is this a good idea? We suggest the introduction of national quality-assured palliative care drug management algorithms to improve patient care and safety in the future document that will replace the LCP.


All web references are active links to LCP documents in the public domain found by the Google search engine.

1. The Liverpool Care Pathway for the dying patient ( LCP ) pathway/ ( accessed July 2014 )

2. Medication Guidance Examples in – LCP Supporting Information ,The Marie Curie Palliative Care Institute, Liverpool, April 2010 /LCP_Medication_Guidance_Document_April_2010.pdf
( accessed July 2014 )

3. Management of Pneumothorax. Clinical algorithms should be standardised.
A. Colman, B. Richards. British Medical Journal, 307, 443, 1993. ( accessed July 2014 )

4. North Yorkshire and York NHS Mental Health Trust Community and Mental Health Services - Liverpool Care Pathway, May 2008 ( accessed July 2014 )

Competing interests: No competing interests

02 July 2014
Andrew W. Colman
Clinical Computer Scientist and Staff Physician
Richard Athey, Consultant Physician with an interest in palliative care, Gateshead NHS Foundation Trust, Gateshead NE9 6SX : Bernard Richards, Emeritus Professor of Medical Informatics, The University of Manchester, Oxford Road, Manchester M13 9PL
Gateshead NHS Foundation Trust
Gateshead NE9 6SX