By Dr. Peter Saunders
Editor’s note. Dr. Saunders is a former general surgeon and is CEO of Christian Medical Fellowship, a UK-based organization with 4,500 UK doctors and 1,000 medical students as members.
The Liverpool Care Pathway (LCP) was developed by specialists in palliative care to improve the management of dying patients but its implementation was dogged by controversy leading to the establishment of an independent review.
The review, chaired by Crossbench Peer Baroness Neuberger, published its report in July.
It concluded that the LCP should be phased out ‘over the next 6 to 12 months’ and replaced by an individual end of life care plan, ‘backed up by good practice guidance specific to disease groups’.
The Government backed the recommendations and said it would ‘consider fully’ the committee’s recommendations over the coming months, to inform ‘a full system-wide response to the review’s recommendations in the autumn’.
The review highlighted a number of issues with the LCP, including, amongst others: specific gaps in evidence on the LCP; difficulty of diagnosing when a patient is actually going to die; issues with decision making and consent; lack of relatives’ involvement in the patient’s care plan; issues with hydration and nutrition; issues with sedation and pain management; a lack of clear accountability in decisions relating to the LCP; a lack of compassion in caring; scarce availability of staff at weekend or out-of-hours.
While acknowledging that prior to the introduction of the LCP ‘the care that patients received was variable and there were many examples of poor care’, the review panel made a number of recommendations for the introduction of an individual end of life care plan which should be developed by a coalition composed of various organisations.
The 44 recommendations made by the panel included the following:
Patients should only be placed on the LCP or a similar approach by a senior responsible clinician in consultation with the healthcare team.
Unless there is a very good reason, a decision to withdraw or not to start a life-prolonging treatment should not be taken during any ‘out of hours’ period.
An urgent call for the NMC to issue guidance on end of life care.
An end to incentive payments for use of the LCP and similar approaches.
A new system-wide approach to improving the quality of care for the dying.
Along with the results of the review, the Department of Health published an Evidence briefing on pathways for the dying phase in end of life care, which formed part of the evidence base used by the independent review panel during its work.
Following the Government’s decision to implement the Review’s recommendations, Care Services Minister Norman Lamb sent a letter to the boards of all acute NHS Trusts asking them immediately to put into effect two actions:
- Undertake a clinical review, led by a senior clinician, of each patient who is currently being cared for using the LCP or a similar pathway for the final days and hours of life, to ensure that the care they are receiving is appropriate and that the patient, where possible, and their family is involved in decisions about end of life care; and
- Assure themselves that a senior clinician is assigned as the responsible clinician to be accountable for the care of every patient in the dying phase, now and in the future.
In addition, the Minister asked that all complaints about pathways for the dying should be ‘investigated properly’, with the appointment of an independent assessor if required. Trusts should also consider whether new evidence exists that would warrant a re-examination by the trust of past complaints about the LCP, in light of the findings of the Review. Finally, they should appoint a Board member with the responsibility for overseeing any complaints about end of life care and for reviewing how end of life care is provided.
On 30 August it was announced that a Leadership Alliance for the Care of Dying People (LACDP) was being set up under the chairmanship of Dr Bee Wee, National Clinical Director for End of Life Care at NHS England, to respond to the Independent Review.
NHS England, the Care Quality Commission (CQC), Department of Health (DH), General Medical Council (GMC), Health Education England (HEE), NHS Improving Quality (NHS IQ), Nursing and Midwifery Council (NMC) and the National Institute for Health and Care Excellence (NICE) have already signed up to join the alliance in order to:
- support everyone involved in the care of people who are dying to respond to the findings of the review;
- be the focal point for the system’s response to the findings and recommendations of the LCP review;
- provide guidance on what needs to occur in place of the LCP;
- consider how best health and social sector can address the recommendations in the review about the accountability and responsibility of individual clinicians, out of hours decisions, nutrition and hydration and communication with the patient and their relatives or carers
- map existing guidance, training and development factors that might affect the adoption of good practice.
The new leadership alliance has a great challenge before it, but I hope that it is able to reach a strong evidence-based census about the next steps forward to ensure that dying patients in Britain are optimally cared for.
It will need to move quickly if public confidence is to be effectively restored.
Editor’s note. This first appeared at pjsaunders.blogspot.co.uk.