Liverpool Care Pathway 'should be phased out'

Marie Curie's Dr Bill Noble says a lot of training is needed to make the pathway work properly

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The Liverpool Care Pathway, developed to support patients as they near death, should be phased out in England, an independent review is expected to say.

The system can involve withdrawal of medication, food and fluids.

It can offer a peaceful and dignified death but there have been problems with its implementation, the government-commissioned review is set to say.

Health officials said the review was expected to recommend the LCP should be phased out within six to 12 months.

'Worrying standards'

The system was developed at the Royal Liverpool University Hospital and the city's Marie Curie hospice in the 1990s to provide a model of best practice in the care of dying patients.

It can mean an end to invasive tests, treatment or feeding through tubes that is deemed to cause unnecessary suffering at the end of life - but it should be discussed with the patient, family or carer where possible.

The Liverpool Care Pathway

The pathway was developed during the late 1990s at the Royal Liverpool University Hospital, in conjunction with the Marie Curie Palliative Care Institute.

It was intended to provide uniform, high-quality, dignified care for dying patients - whether they were in hospital, at home, in a care home or in a hospice.

Previously, there were concerns that care had been patchy, with some hospitals failing to meet acceptable standards, and accusations that people were subjected to invasive treatment and testing that offered no chance of preventing death, but merely prolonged their suffering.

Under the LCP, patients are regularly reviewed to ascertain whether medication should be stopped - and whether fluids should be withdrawn once they have ceased to be able to eat and drink.

However, families have complained relatives were put on the pathway without their consent, and that death has been hastened in people who were not dying imminently.

Critics say that it is impossible for doctors to predict when death is imminent, so the decision to put a patient on the pathway is at worst self-fulfilling.

There have also been suggestions that the pathway has been used to help hospitals save money. NHS Trusts do receive payouts for hitting targets related to its use - but the suggestion that the pathway has been used for cynical reasons has been vigorously denied by the Department of Health.

The Department of Health (DoH) in England set up an independent review amid fears the LCP was being used to hasten death, to clear beds and save money, and that patients or their families were not being consulted.

The review, led by crossbench peer Baroness Julia Neuberger, applies only to England. The LCP is also used in Scotland and Northern Ireland but not in Wales, which has its own framework for end-of-life care and support.

A Scottish Government spokeswoman told the BBC it welcomed the Neuberger review.

"Recommendations set out in the report will be considered by the Living and Dying Well National Advisory Group, so that any learning for Scotland can be taken forward with stakeholders," the spokeswoman said.

The review for England was asked to focus on the use of the LCP model rather than re-evaluating its basic merits.

But the DoH said the review team, which heard evidence from patients, families and health professionals, encountered "numerous examples of poor implementation and worrying standards in care".

The review was likely to conclude the LCP needed to be replaced, it said in a statement.

"The independent review into end of life care system the Liverpool Care Pathway, commissioned last year by Care and Support Minister Norman Lamb and backed by Health Secretary Jeremy Hunt, is likely to recommend that the LCP is phased out over the next six to 12 months," the DoH said.

The statement gave no indication of what might replace the LCP.

But Mr Lamb said: "We need a new system of better end-of-life care tailored to the needs of individual patients and involving their families."

'Unacceptable cases'

He ordered the review in November last year amid intense media scrutiny of the LCP following criticism from patients' families.

Start Quote

When it comes to dying we cannot afford to get it wrong and health professionals need to be supported to communicate with people effectively”

End Quote Jason Suckley Director, Sue Ryder

At the time, he said he was concerned about the "unacceptable" cases that had come to light.

British Medical Association president elect Baroness Finlay said the LCP was originally brought in because patients were "dying badly, in hospitals in particular".

They were being "walked past, ignored and neglected", she said, and the LCP was an attempt to "roll out the best of hospice care into other areas".

"By and large that worked well but the problem has been that it hasn't always been used properly," she told BBC Radio 4's Today Programme.

She said that if the LCP was phased out it was vital something better replaced it. "Something which is very clear, very simple and which drives up professional behaviour," Baroness Finlay added.

Dr Linda Patterson, clinical vice-president of the Royal College of Physicians - which has been reviewing the LCP every year since it was introduced in 2004 - said the system was "very helpful".

"But if the execution of it in all instances has not been right then we need to review that," she added.

"All doctors dealing with patients who may unfortunately die need to be trained in end-of-life care. We need to know what the standards are, we need to be able to apply them, our junior doctors and trainees need to be fully trained in it. And we also need time - time to be able to discuss these very difficult issues."

Jason Suckley, director of policy and campaigns at Sue Ryder, said the healthcare charity's research had shown the timing and quality of conversations health professionals had with terminally-ill patients amounted to a "lottery".

He said workers' communication skills needed to be improved and urged Health Education England, which provides training and support for healthcare professionals, to include end-of-life training in its workforce mandate.

"When it comes to dying we cannot afford to get it wrong and health professionals need to be supported to communicate with people effectively at a very traumatic and emotionally difficult time," he said.

The review's findings are due to be published in full on Monday.

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