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We need an alternative to the Liverpool care pathway for patients who might recover

BMJ 2013; 346 doi: (Published 11 June 2013) Cite this as: BMJ 2013;346:f3702

Re: We need an alternative to the Liverpool care pathway for patients who might recover

The Liverpool Care Pathway (LCP) has been criticised extensively in the popular press in the UK and abroad for speeding up the process of death. Surprisingly, a small percentage of patients on the LCP who were thought to be dying did actually improve. A number of such cases of ‘spontaneous recovery’ have been reported in the newspapers as proofs of the wrong use of the LCP. However, what is missing from these reports is a proper inquiry as to the actual cause of the improvement of these patients’ conditions. Most professionals, including Mr Parker, attribute these clinical recoveries to incorrect diagnosis of dying and/or wrong estimation of prognosis (Parker, 2013). We would like to offer another suggestion in this emotive debate, namely the possibility that the LCP has been directly responsible for the clinical recovery of some of these patients. In other words, the possibility that the LCP actually saved these people’s lives.

During a case note review of nine hospital patients who had improved after being started on the LCP, we noticed some common characteristics. They were:
• elderly (83-98 years old), with multiple co-morbidities (six with dementia and only one with cancer) and on multiple medications
• malnourished, although significantly not always underweight OR had lost a significant amount of weight recently
• put Nil By Mouth (NBM) by healthcare professionals (either doctors, nurses or speech and language therapists) to prevent aspiration OR had reduced oral intake for a number of days
• given regular intravenous (iv) fluids and
• in four cases later started on artificial nutrition via a nasogastric tube (NGT).
When they deteriorated and were thought to be dying, the LCP was used for their care and all drugs, iv fluids and NGT feeding were discontinued. After a few days they improved clinically. In two cases, artificial feeding and/or hydration were re-started with a subsequent second deterioration, second use of the LCP and second improvement when iv fluids and/or artificial feeding were stopped. One of these patients lived for a further ten months.

We recently reported three of these cases in the journal of the Royal College of Physicians Clinical Medicine concluding that, elderly patients who handle excess water and salt badly can deteriorate as a result of over-hydration (Tsiompanou, 2013). Furthermore, if they are unable to eat orally or are kept NBM for a number of days and then fed artificially, they are at high risk of re-feeding syndrome. In these cases, we propose that the use of the LCP contributed to their clinical improvement as a result of the withdrawal of excessive feeding and/or hydration.

Although the risks of over-hydration are well known, clinicians may underestimate the contribution of excessive iv fluid administration to patients’ deterioration. The National Institute for Health and Clinical Excellence (NICE) in England has recognised the need for guidelines for the intravenous fluid therapy of adults in hospital, which are currently under development. The risks of re-feeding syndrome are less well acknowledged, primarily due to the non-specific symptoms that patients develop, which can mimic other conditions including dying. Doctors, nurses and dietitians need to be alert to the possibility of re-feeding syndrome when there is any sign of clinical deterioration.

We are aware that our clinical observations, which are based on a few cases, cannot be generalised. It is however very difficult to perform studies on re-feeding syndrome and protocol-based IV fluid studies in medical patients. Given that the LCP is currently used widely on medical and surgical wards in NHS hospitals and palliative care settings in the UK, similar cases of clinical improvement may also be due to the withdrawal of excess artificial nutrition and iv fluids in patients. Perhaps, the annual National Care of the Dying audit could look in more detail into the characteristics of patients who improve and are taken off the LCP.

Parker, MJ. We need an alternative to the Liverpool care pathway for patients who might recover. BMJ 2013;346:f3702

Tsiompanou E, Lucas C & Stroud M. Overfeeding and overhydration in elderly medical patients: lessons from the Liverpool Care Pathway. Clin Med 2013;13(3): 248–51

Competing interests: No competing interests

24 June 2013
Physician in Palliative Medicine
Mike Stroud
Kingston Hospital NHS Trust and Princess Alice Hospice
West End Lane, Esher, Surrey KT10 8NA