A good death for all?
In their recent article1 Ellershaw and colleagues once more offer a
well rehearsed defence of their Liverpool Care Pathway (LCP). Faced by an
ageing population and the contraction of secondary care, the LCP has
obvious appeal in straitened times. However, it has proved controversial,
and despite the best part of a decade of unprecedented and ongoing
'education' of staff in its use, reports of misuse remain disturbingly
It is widely acknowledged that despite decades of research in the
care of patients with cancer, the accurate prediction of dying, that is
the last 48 hrs of life, remains difficult3 4 5. The need for accuracy is
obviously of great importance to patients and to next of kin. It was
therefore surprising to read that Ellershaw et al feel that the gross lack
of data supporting accurate prediction of dying in the 70% of deaths not
due to malignancy is of no significance, and that evidence of widespread
use obviates the need for evidence that such usage is safe and
appropriately timed. This argument suggests that 'evidence-based' medicine
has a long way to go.
Ellershaw and colleagues briefly mention three areas of LCP practice
shown by the National Audits to be in need of 'improvement'. However to
describe 'communication' as merely needing improvement is far too modest,
rather like describing bankruptcy as a minor cash flow problem. In fact
both the 2006-20076 and the 2008-20097 Audits show that the majority of
patients on the LCP are unaware that they are dying, and only around half
are even aware of their diagnosis. The results for meeting spiritual and
religious needs are even worse. These failures are not simply medically
anachronistic, they are dishonest and inhumane.
Indifference to the need for accurate diagnosis of dying, and
indifference to the most basic needs of patients and next of kin, go
deeper than a lack simply of 'education' and suggest fundamental flaws in
the approach adopted by the LCP project. 'Achieving a good death for all'
would appear to remain a distant goal.
Dr R J Clearkin
Market Harborough LE16 8EL
1 Ellershaw J, Dewar S, Murphy D. "Achieving a good death for all".
BMJ 2010; 341: 656-658
2 Le Fanu J. "Clinging to a Pathway can lead care off track". The
Daily Telegraph 20.9.2010
3 Riley J. "A strategy for end of life care in the UK". BMJ.
4 National Gold Standards Framework Centre England. Prognostic
Indicator Guidance Paper ? Gold Standards Framework Centre. England 2008
5 National Care of the Dying Audit - Hospitals (NCDAH); Generic
Report 2006/2007 p.23
6 National Care of the Dying Audit - Hospitals (NCDAH); Generic
7 National Care of the Dying Audit - Hospitals (NCDAH); Round 2,
Generic Report 2008-2009
Competing interests: No competing interests