The recent media storm over the Liverpool Care Pathway has obscured the progress doctors and nurses have made over the past decades in the UK in improving care for patients who are near death. Since the LCP was developed, patients in busy hospitals and other institutions are less likely to be left to die in pain and discomfort.
The Pathway itself is simply a framework which reminds professionals to consider, and document, the process of care for people in the last days of life. Without it, some professionals may struggle to shift their focus to important aspects of care such as comfort measures, pain control, communicating with, and supporting, the family, carers and friends. It does not replace clinical judgement, and it is not irreversible – if the diagnosis of dying turns out to be premature, patients can be taken off the pathway.
However, it is clear from recent media stories that relatives believe that some seriously ill patients have died prematurely as a result of being treated, or mistreated, under the Pathway, and these concerns should be taken seriously and investigated. If there is something wrong with the LCP or with the way it is being put into practice in certain quarters, we need to get at the facts and take corrective action. Equally, if the allegations are based on, for example, misunderstandings, that too needs to be established so that dying people and their families are not caused needless anxiety.
If anyone should have any concern about the way clinical care is being provided, they should bring their concerns to the attention of the local health care trust so that they can be investigated. I can understand why families may be reluctant to do that at such a difficult time. What is needed is a careful and unbiased sifting of any evidence that exists to reach the truth and take steps to improve practice.
Recognising when somebody is likely to die within days or even hours requires skill and experience. Sometimes, it’s obvious; other times, it can only be based on judgement and experience. Even then, vigilance, repeated assessments and a willingness to revise the decision are all part and parcel of good care. When someone is close to dying, they are often unable to swallow food and fluids. That’s a natural part of what is happening. For some, providing artificial fluids may add comfort; in others, it often makes the situation worse. Every decision must be based on carefully balancing the benefits versus burdens to the patient of anything we do. In doing so, doctors and nurses need to talk to patients and families – communication is a crucial part of good care.
It is possible that some doctors and nurses are not putting the LCP into practice appropriately, or communicating with patients and their families, as they should. Such shortcomings exist in all professions. Equally, doctors and nurses themselves should not be over-defensive. Britain is indisputably a world leader in palliative care but there is always room for improvement in the best clinical practice. So this is a good opportunity to step back and look at the care we provide for dying patients, without necessarily defending or attacking the LCP, which is only part of the bigger picture of end of life care.
Dr Bee Wee is president of the Association for Palliative Medicine of Great Britain and Ireland and a Consultant/Senior Lecturer in Palliative Medicine at Oxford University Hospitals NHS Trust and the University of Oxford.