Re: The Liverpool care pathway: a cautionary tale
As general practitioners and palliative care researchers in Antwerp (Belgium), we feel somewhat confused about the recent withdrawal of the LCP. That is why we read some documents published on the internet along the implementation and research history of the LCP, to understand better what happened. A selection of those documents is cited here.
Reading the ‘Frequent Asked Questions’-section about the Liverpool Care Pathway (LCP) prepared by its funders and developers, you find that the LCP has been designed to be used caring well for the individual patient and communicating well with the patient and his or her family.1 That exactly is the basis of good clinical care, contrasting with all the real-life stories about the side-effects of using the LCP.
We have been thinking of possible causes of the LCP’s withdrawal. Perhaps, it is not because its original design, being a summary of actions based on a lot of clinical experience and evidence, well put together in a care pathway.2 Perhaps, it is not the education about it: there are several published articles, well-accessible websites about it, and most importantly the LCP being part of the UK national End of Life Strategy. As such, its educational program was well supported by government and clinical leaders.2 Perhaps, it is not a lack of studies to evaluate the implementation and effect of the Care Pathway – and those evaluation studies were all globally positive, and already in 2009 pointing at a lack of palliative care (communication) skills of care providers in the hospitals.2
Perhaps, the problem has been a lack of courage of (local) health care managers. Has there been performed any local quality of health care assessment? Probably yes, in these over-assessed times. Then, what has been done to tackle the noticed problems that became clear from the assessments and evaluations?
Did the (local) health care managers and commissioners take measures to prevent junior health care providers starting LCP on their own? Did they provide the right preconditions for correct support of senior doctors and palliative care specialists? Did they stimulate an atmosphere where interdisciplinary discussions are ‘normal’ and productive? And last, but not least, are we sure the right questions are asked on our assessment tables – is it not the patient’s and family’s opinion being more important than the health care providers’ processes? Off course, even if health care managers noticed some problems as mentioned above and had the courage to change underlying causes like ‘working habits’ and ‘personnel shortage’, then they’ve just begun doing so. Succeeding there isn’t an easy task at all.
If there is insufficient interaction between hospital staff and primary care team, the patient’s wishes might be unknown by the involved health care professional. Hospital staff might not be trained well enough in the indeed difficult palliative care prognosis and communication skills. Adding these difficulties together, it might not be surprising that problems arise.
Our research group has been reflecting on this matter, because it is related to our own project. We are starting the implementation of a Care Pathway of Primary Palliative Care (CPPPC) in five regions in Belgium, to be used in a first phase by the primary health care team, aiming to extend it later on by hospital staff. This CPPPC will start with early identification of palliative patients by using the Surprise Question and the Supportive and Palliative Care Indicators Tool. The second step is individualized advance care planning, aiming to design an individual care plan that grows over the time, fed by multiple discussions with all stakeholders taking care of the palliative patient, including hospital staff. We hope that, from a long-standing relationship and “knowing the patient’s and family’s wishes”, this way of providing care will lead to a better palliative as well as end-of-life care, both in the outpatient and in the inpatient settings .
We believe that to evaluate a complex intervention like our Care Pathway it is not enough to find associations and correlations in quantitative databases. We will evaluate the CPPPC by quantitative means, but partly inspired by the LCP cautionary tale, we will also interview users of our Care Pathway (health care professionals, patients and family members) to find the specific contexts in which and psychosocial mechanisms through which the CPPPC works the best, and in which it doesn’t work.
Competing interests: No competing interests