90% of doctors 'support Liverpool Care Pathway'

“Ninety per cent (of doctors) would be prepared to be placed on the controversial Liverpool Care Pathway programme if they were nearing death” is the reassuring news in today’s Metro.

The Daily Telegraph strikes a more downbeat note with the claim that ‘fifth of doctors queasy about always telling relatives’. This view would go against official advice from care minister Norman Lamb that no patients should be put on the controversial Liverpool Care Pathway ‘without a proper explanation or their families being involved’.

Both reports come following an opinion poll of palliative care specialists, asking them about their views on the Liverpool Care Pathway (LCP).

Out of more than 3,000 UK doctors contacted during the survey (commissioned by the BMJ and Channel 4’s Dispatches programme), 563 with experience in use of the LCP responded.

The results of this survey were overwhelmingly positive, 91% of those who responded thought that the LCP represented the best care for a person who was dying and helped them to die with dignity. Also, 90% of respondents said they would be happy to be placed on the pathway themselves if they were dying.

What concerns have been raised about the Liverpool Care Pathway?

The LCP has been widely used for over a decade without attracting much attention. But in 2012 the LCP seemed to become a ‘hot topic’ for the newspapers, attracting a lot of coverage throughout the year.

Some of the coverage raised legitimate concerns, such as:

• people may be put on the care pathway inappropriately
• people being placed on the care pathway without discussion with the family and person themselves, if this is appropriate

While some of the coverage was downright lurid, with completely unsubstantiated claims that hospitals were putting people on ‘death pathways’ in a cynical attempt to save money and free up beds.

Criticism of the LCP in recent months has led to ongoing reviews by the Department of Health and the NHS National End of Life Care Programme.

How was the survey carried out?

The current media reports come following publication of an article in the British Medical Journal (BMJ) which reports on the findings of a BMJ survey conducted in conjunction with Channel 4’s Dispatches.

Last month, the BMJ emailed 3,021 UK hospital doctors asking them to participate in an anonymous online survey of their views on the Liverpool Care Pathway.

Only 21% of those invited to participate (647) agreed. Of these people, 87% had used the LCP, and these 563 doctors were included in the full survey.

They represent 185 palliative medicine consultants (roughly 40% of the UK total), 168 doctors in palliative medicine training posts, and 210 doctors in other specialties, but with some experience in palliative medicine.

What were the main findings of the survey?

The main findings reported in the BMJ article from the 563 doctors who completed the survey are as follows:

• Over half of the 563 doctors (57%) thought recent negative press coverage had led to the Liverpool Care Pathway being used less.
• Almost three quarters (74%) of the palliative medicine consultants surveyed held this view that negative press coverage had led to the Liverpool Care Pathway being used less.
• Among the 321 doctors who said there was less use of the pathway, 60% (194) said patients and relatives had asked them not to use it, and 80% (258) said staff were apprehensive about relatives’ complaints.
• Encouragingly, almost all of those surveyed (98%) did not think that pressure on beds or other resources had influenced decisions to use the pathway for end of life care. This is despite previous suggestions in the media that the Liverpool Care Pathway is used to ‘save money’ or to ‘dispatch patients because hospitals need their beds’.
• Only 13% of doctors said hospitals should be offered financial incentives for using the pathway; 58% were against financial incentives.
• Of the 210 doctors in non-palliative medicine specialities, 92% thought that doctors and nurses were able to judge when a person was dying. However, only 78% of the palliative medicine consultants agreed with this and felt that recognition of a dying patient and communication of this to patients and relatives was a particular training need.
• 91% of those surveyed thought the Liverpool Care Pathway represented best practice care for the dying person. If used properly, 98% thought it allowed patients to die with dignity, with only two respondents (0.4%) disagreeing with this.
• When asked if they would want the pathway during a terminal illness themselves, 90% of all doctors said yes and 3% said no.

The survey did raise some concern among doctors though, and principle among these was a need for extra training in the assessment and recognition of people who are coming to the end of their lives.

One trainee doctor said: “High levels of staffing are required to implement it properly. Doctors must have the time and training to communicate with families, and the proper implementation of the LCP requires highly trained nurses.”

The president of the Association for Palliative Medicine also highlighted a lack of training: “We know that there are some hospitals where the Liverpool Care Pathway is introduced, there is very little training of the staff, there is nobody who is going around making sure that it is used correctly”.

As the author of the BMJ study concludes, ‘doctors should use the opportunity to promote further education, training, and improvements in the care of dying patients.’

What concerns did doctors raise about the media coverage?

A particular concern among many doctors was about relatives’ apprehensions regarding use of the pathway, and that doctors may face complaints if patients were put on it. One palliative medicine doctor is quoted as saying “Negative press regarding LCP [the pathway] has caused additional distress for relatives at an already distressing time when their loved one is dying. This has caused a dilemma in judging if discussing the LCP will cause more distress than the benefit of being on the LCP for coordination of care in the dying phase.”

Another specialist is quoted as saying that despite concerns, people still recognise the aims of the pathway: “Often where families have been against the use of the LCP because of the negative press, they have been in agreement with application of its principles.”

Conclusion

A key issue raised by doctors in this survey was a need for extra training in assessing and recognising when people are coming to the end of their lives. Around a quarter of surveyed palliative medicine consultants felt that doctors needed more training to help them recognise that a patient was dying, and in how to communicate this to them and their relatives. As one consultant said: “There are undoubtedly cases reported in the press where end of life care has not been managed well. These should be criticisms of training, assessment and common sense. They are not correctly directed at the pathway.

“It is as irresponsible as banning insulin because of the damage and deaths that have occurred over the years due to inappropriate, inaccurate or malicious use of this drug”.

While this news is limited by the fact that it is based on an emailed survey, those who chose to respond are likely to be those with the most experience in using the pathway, its sample does represent a significant proportion of the UK experts in this field. The outcome of the reviews of the Liverpool Care Pathway are awaited, but patients, friends and family should take comfort from this news that the majority of doctors – in this survey – appear to support its use.