Monday, 26 November 2012

What if Dr. Shipman had the Liverpool Care Pathway?

I have to apologise for the controversial potentially inflammatory title of this post, but if it makes someone read what I have to say on the matter, then it would have achieved something.
The Liverpool Care Pathway has had really bad press recently and I am afraid that the blame for that rests not with the Daily Mail or some other rag everyone loves to hate but with the medical/healthcare profession. For those not in the know, the Liverpool Care Pathway is a Care Pathway designed to help health carers look after patients who are dying. It tries to reproduce everything that is good about hospice care and to spread this good practice elsewhere. It was designed by the Marie Curie Palliative Care Institute in Liverpool, hence the name. It is accepted all over the world as good practice.

I have reproduced the list of 10 key messages from the document published by the LCP team.


Points 1,3, 5 and 7 really stick out for me.
Point 1 is obvious and the title of this post relates to this . Undoubtedly Dr Harold Shipman would have been a great fan of the LCP. He would have devised his own indications, being over the age of 70 being one.
Point 3 flashes out to me like a beacon - communication not just between heath care workers, but crucially with relatives by personnel who know how to communicate with the relatives of the dying.
Point 5 is also important (as are all the points!). The burden of responsibility (and it is a huge responsibility) of making the diagnosis of dying should lie on the shoulders of a team of healthcare workers and not on those of one individual.
Point 7 - No human should die thirsty - withdrawing hydration is just inhumane!

I know that very occassionally one gets malicious relatives who go to the press, a press that often behaves irresponsibly. Nonetheless I have read some of the recently published stories relating to the LCP. These have been accounts of relatives of patients who have been put on the LCP. It seems clear that on occasions, not every point listed above was followed. Every time this happens, the LCP, those who use it properly, the NHS and the UK generally are ill served. I know from personal experience there are many people overseas who now genuinely believe that the elderly are being euthanised in the UK to save money - the misconception is that incredible and that horrible!
There are some care pathways where slight variation from the operating rules do not make a big difference. The LCP is not one of them and the key messages must be followed to the letter.
I am a great fan of the LCP and the writers of this care pathway should be publicly lauded for their great effort in continuing the great work started by Dame Cicely Saunders in ensuring a practice that exudes great humanity. However, I would have thought that in view of what has been happening over the past few weeks, audit of the use of LCP ( as made in point 9) should be made mandatory. Points 2-8 should be the Gold Standard against which practice is measured.
On a final point, I was not terribly impressed by the message put forward by the letter to the Daily Telegraph signed by many healthworkers saying that if dying they would choose the LCP as their preferred way of dying. That may be so and I probably would also have that preference. But doctors dictating to patients on the way they should die is hardly a good example of shared care decision making - the mantra that should dictate the way all health workers should operate.