In defence of the Liverpool Care Pathway
The panic spread by hacks and politicians about end-of-life care in UK hospitals needs to be tackled head-on.
Earlier this month, the Department of Health announced changes to the NHS constitution to make it a legal requirement for doctors to discuss with relatives before putting patients on the ‘Liverpool Care Pathway’ (LCP), a protocol for managing care at the end of life. Coming after a week of increasingly sensationalist headlines about ‘The medical profession’s lethal arrogance’ and ‘Hospitals bribed to put patients on pathway to death’, mainly in the Daily Mail and Daily Telegraph, this might seem like a sensible protection for vulnerable patients. But what is the LCP? And what does this row tell us about the current state of healthcare in the UK?
The LCP was developed to provide a framework for the management of dying patients, to bring the best practice of end-of-life hospice care on to hospital wards. It allows the fact that the patient is dying to be recognised by the medical and nursing team, so they can provide the special care and attention this situation needs.
It involves stopping some procedures, like routine blood tests, and rationalises the medication a patient is on – for instance, stopping long-term preventative drugs such as cholesterol-lowering statins. In addition, it prompts the medical team to write prescriptions for drugs that alleviate symptoms, such as midazolam for anxiety.
Artificial nutrition and hydration can be stopped, too. Contrary to popular opinion, this doesn’t involve starving and dehydrating the patient to death. No one is stopped from eating and drinking, and they would be helped to drink if they were thirsty. A patient’s demand for food and fluid reduces as they approach death, and stopping artificial hydration cuts out the need for potentially painful repeated cannulation. The subjective feeling of thirst and fluid intake are often poorly correlated, and hydration is balanced against a number of other equally unpleasant symptoms in a dying patient, such as incontinence, and fluid in the mouth and lungs. It is a complicated medical judgement call, and there is no one mandated answer; the LCP does not preclude hydration.
Another integral part of the pathway is communication with the patients and their relatives; most importantly, an articulation that the patient is dying. It allows for discussions about where people want to die, who they want with them, and what religious involvement they want.
The latest intervention by the Lib-Con secretary of state for health, Jeremy Hunt – which makes it a legal requirement to inform relatives about the use of the end-of-life pathway – gives further credence to the insulting idea that doctors are not acting in their patients’ best interests and need further legal monitoring to make them act correctly. It turns best (and usual) practice into legal writ. It is an attempt to legislate crudely for the deeply complicated and emotional process of caring for and talking to someone who is dying and their family. By bringing law into these discussions, Hunt’s intervention promotes defensive medicine, promoting the easiest option rather than what is best for the patient, as well as assuming that fundamentally human characteristics such as empathy and compassion need to be written into law.
Furthermore, this furore once again highlights the medical profession’s inability to defend itself, bringing to mind the MMR vaccine debacle and the changes to the system of postgraduate training, Modernising Medical Careers. We are in a situation whereby a government minister is mandating a basic aspect of medical management, and interfering in one of the most intimate interactions between healthcare professionals and patients, and the response has largely been defensive and apologetic.
While there have been some spirited and robust defences of the LCP from within the profession, and while some medical institutions have spoken out, others, such as the Association of Palliative Medicine, have been confused at best in their response. After initially seeming to call for an inquiry into their own practices around the LCP, they have now backtracked to come out in its defence. Unfortunately the majority of the defence has appeared in professional outlets like the British Medical Journal, while there hasn’t been the much-needed broader campaign from the medical establishment aimed at the general public, to assuage fears and correct misconceptions.
While it would be naive to suggest every death in this country, whether on the LCP or not, has been the pinnacle of good medical care, the LCP has been a step forward in ensuring best practice at the end of life, and moving away from seeing death as a medical failure. But this debate isn’t just about the specifics of the LCP, but is also about the wider issue of medical deprofessionalisation – whereby the media and politicians can dictate medical management, undermining the patient-doctor relationship, while the medical profession just sits back and watches.
Fiona Alderton is the pseudonym of a doctor in hospital medicine.