The Liverpool Care Pathway has been made a scapegoat

“It is as illogical to discredit the LCP because of errant clinicians as it is to ban the Highway Code because of bad drivers.”

Claud Regnard, FRCP, a palliative care consultant, has called the demise of the Liverpool Care Pathway a “tragedy” in his paper published in Age and Ageing today.

After a series of media stories about the palliative care system causing malnutrition, dehydration, and premature death in patients across a wide age-range, the Liverpool Care Pathway (LCP) was subject to review by a panel under Baroness Neuberger. The panel delivered their findings on 15 July 2013. They said that the LCP needed to abandon its name, as well as the use of the word “pathway”, and that the LCP should be replaced within 12 months by an “end of life care plan”.

Claud Regnard rejects some of the Neuberger report findings, saying that the LCP has been made “a scapegoat”.  The review lists the many reasons for poor care and communication but found no evidence that the LCP was the cause of poor care.

Regnard also calls some of the report’s recommendations “puzzling”, stating that “their suggestion to replace the LCP with an “end of life care plan” creates a plan with death as an end point, the same criticism they levelled at the LCP. They also expect the Care Quality Commission to carry out a thematic review within 12 months of how dying patients are treated, which Regnard describes as “rather like setting a handwriting test but confiscating the only pen beforehand.”

“The most puzzling omissions were not to consider the distress of partners and relatives at the mention of a document that had been discredited by a national review and to make no provision for a replacement tool.”

Regnard does say that the LCP could have been improved, suggesting that audits could have focused more on delivery than documentation, and that training should have been made mandatory, but argues that the LCP itself was not the cause of poor care. Discrediting it, he warns, “will ensure that those who remain ignorant or negligent will continue their poor practice without fear of being discovered for the years it may take to produce an alternative.”

However, the Neuberger report does contain components that he believes will be of benefit to patients, particularly the plea for personalised care and the proposal to set up a national alliance looking at end of life care.

Regnard says, “the death of the Liverpool Care Pathway was preventable, an irony that was lost in the rush to pronounce its demise and promote the message of a listening government. It is as logical to discredit guidance because of errant clinicians as it is to ban the Highway Code because of bad drivers.”

The full paper can be read on the Age and Ageing website.

The BGS Consensus Statement on the Liverpool Care Pathway can be read here.

5 thoughts on “The Liverpool Care Pathway has been made a scapegoat

  1. Pingback: The Liverpool Care Pathway has been made a scapegoat | British Geriatrics Society | All Things Palliative - Article Feed

  2. I agree with Claud about quite a lot, but we have a fairly basic disagreement about some Mental Capacity Act issues. But I’m not sure that Claud is correct (as reported here) in thinking that the Neuberger Review was actually ‘tasked’ with getting rid of the LCP – my feeling is that it was ‘tasked’ with rehabilitatiing the LCP, but found so many things ‘tainting its name’ that the Review Team concluded the LCP had to go, as it was [in the eyes of the public] beyond saving. I’ll read Claud’s full article, before commenting any further.

  3. I hope this comment, typed in Word, pastes in correctly: I’m having problems with checking what is actually inside that comments box on the website.

    I have now read the full paper, and I agree with a lot of what Claud writes in it. In particular, the word ‘plan’ seems to imply even more pre-determination (towards death) than ‘pathway’ did; although the actual proposal is for a longer-term (than final few days of life) ‘thing’ called a Personalised Palliative Care Plan, with an emphasis on ‘personalised’.
    Although the proposed replacement for the LCP is provisionally called a Personalised Palliative Care Plan, and it covers a longer period than ‘the final few days’: also, the emphasis is on ‘personalised’.
    Where I have an issue with Claud, is that although the LCP when used correctly, by HCPs who understood the principles of good EoL care and behaviour, was fine, the Neuberger Review did find lots of instances where it wasn’t being used appropriately – Claud’s paper points that out. There has been plenty of time for the medical establishment to get the training right, but that obviously had not happened, and Claud does not explain how if the LCP were retained, he would make sure that all HCPs ‘get it right in future’.
    In any event, understanding what palliations are effective, and understanding the law around dying and death, and indeed ‘thinking with logic and compassion’, shouldn’t need to be bundled up as ‘an item with a name’, anyway. It shouldn’t be difficult – as I wrote on the Nursing Times website in its comments facility:

    I’m really troubled by this one, because it is now very clear that the LCP ‘failed’ because it was being used by staff who ‘did not get the point’, or in places where clinicians were not given enough time ‘to behave as if they understood the point’.

    Yes, the effectiveness of palliative treatments should be properly assessed, 100% absolutely. So that you are reasonably sure that you are OFFERING the best treatments to patients.

    But ‘dying’ isn’t simply about the clinical process of death: patients are individuals, as are the relatives and friends of patients, and people and families, and their familial interactions, are not all the same – two patients who are in ‘identical clinical situations during dying’ can nevertheless still have very different personal objectives and preferences, and indeed different personal tolerances of different issues. Some patients will prefer more discomfort during dying provided they can die at home, and for others that will not be true. Some patients will prefer to be in more pain but ‘alert so I can talk to my family’ but others will not.

    The Independent Review of the LCP was very clear that some entirely unacceptable things were frequently happening – for example, nurses deciding to deeply sedate patients without asking for permission to do that. Etc.

    People are not tins of baked beans – dying patients are individuals, and should be treated as INDIVIDUALS and not solely on the basis of ‘their clinical situation’.

    Another major problem with the LCP, is that it was developed with cancer patients whose prognoses are much easier to anticipate than the prognoses of patients with complex co-morbidities, but it had been rolled out to these more complicated clinical situations, without adequate modification.

    The LCP Review made it very clear what had gone wrong with the LCP, and their report is definitely worth reading if anybody wants to understand that:

    https://www.gov.uk/government/publications/review-of-liverpool-care-pathway-for-dying-patients

    The LCP Review also published some other supporting literature. And, the Review Team was clearly so disturbed about what it discovered, that it wandered ‘off-brief’ (its ‘original brief’ was really to rehabilitate the LCP, after The Mail et al had been ‘trashing it’: in fact, the Review Team decided it was so badly tainted, it should be scrapped instead).

  4. There is another comment worth making, about the use of terms such as ‘pathway’.

    Claud explained in his paper, that to clinicians ‘pathway’ has a quite technical and complex meaning, but its meaning in ‘plain English’ is rather different. This use of an existing word, to describe a somewhat different concept within a specialist group [such as of clinicians] inherently leads to lay-professional confusion and misunderstanding. Claud explained in his paper what ‘pathway’ means to a clinician:

    ‘The LCP is an integrated care pathway. These are patient-centred multidisciplinary care plans that identify the care needed for patients with specific problems and provide a means of auditing that care.’

    It is easy to understand why professional groups adopt terminology which acts as ‘shorthand for a wider concept’, but by adopting commonly-used words, confusion can easily result. This is demonstrably true for the term ‘expected death’, and if the LCP was indeed for ‘the final few days of life’ then all LCP patients would logically be ‘expected death’ (although one would not expect every LCP patient to die). But even amongst healthcare professionals, the term ‘expected death’ isn’t always properly understood and correctly used, as I explained in my paper at:

    http://www.bmj.com/content/347/bmj.f4085/rr/654490

  5. I came to an identical conclusion in ignorance of this paper. I responded (twice) to the summary of NICE EOL guidance in the BMJ at h6631. I was interested in scapegoating in general and how it acted to divert attention from potentially remediable, complex realities of implementation.

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