Abstract
Dear Editor:
“Use of the Liverpool Care Pathway should be replaced over the next 6 to 12 months by an end-of-life care plan for each patient, backed up by condition-specific good practice guidance.”
This recommendation in July 2013 by the independent review of the Liverpool Care Pathway, “More Care, Less Pathway,” 1 was a further episode in the travails of the Liverpool Care Pathway for the Dying Patient (LCP). A wound opened in September 2009 following publication of a letter critical of the LCP 2 was further excoriated by more adverse publicity in the British press late in 2012; one result was the independent review.
The LCP is widely used in the United Kingdom and New Zealand both of which have adopted a national approach; its use in Australia is sporadic as is the case in other parts of the world. The pathway appears to be shouldering the blame for what is largely poor practice in the management of the complexities of end-of-life care and its associated decision making processes. These problems will not be addressed by any pathway. Neither can we conclude that jurisdictions where the LCP is not in use are free from these problems. Indeed, it may well be that the LCP has set a standard of care that has not been achieved, a deficiency only uncovered by having that yardstick against which to measure the adequacy of the care provided; and, possibly, for that we should thank the LCP.
What becomes the end-of-life can be a hazardous time, and what data is available suggests that in Australia and New Zealand practitioners are prepared to act knowingly to influence the timing of a patient's death;3,4 it seems improbable that this is a unique experience. 5 Deficiencies in care at the end of life should properly be seen in the context of patient safety, an issue to which palliative care has, until recently, paid little attention. Importantly, in addition to traditional medical hazards, palliative care carries risks related to decision making processes around the end of life, risks to which both health care professionals and family members can make a contribution and which have the capacity to influence the timing of death. It should also be acknowledged that the LCP has made its own contribution with a naïve tick box approach and a dubious ethical silence on supportive care that was not addressed until version 12 late in 2009.
Whatever we may want the LCP to be, it is simply a tool, nothing more or less; despite being viewed as such, it is not a treatment and has no life other than that given to it by the players in end-of-life care. Its removal is not a solution. The palliative care community was reluctant to acknowledge and address the problems sketched in the original newspaper articles. The rock that is end-of-life care has now been lifted on our behalf and we should take the opportunity to see what lies underneath our own one, however unpleasant that may be.
The views expressed here are my own and are not intended to represent the views of my employer.