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Another Look at the Liverpool Care Pathway

September 29, 2013
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Here is a piece I wrote for the Medical Student newspaper, forming one half of a head-to-head debate. Read the whole story here:

In July of this year, Baroness Neuberger concluded her review into the use of the Liverpool Care Pathway (LCP) for patients at the end of life. She recommended that the pathway be phased out in favour of personalised care plans for terminally ill patients. This came after a furore, largely stoked by the Daily Mail, over the mis-treatment of patients on the pathway.

There were reports that patients were denied food and water to hasten death, and that, instead of quality of life, the LCP was used as a tool to clear beds, save money and earn extra financial incentives. Previously, I have defended the pathway as a means of achieving a good death, the final chapter of a good life. I still believe in the LCP in theory, that minimising pain, distress and pointless or invasive medical interventions is what compassion looks like at the end of life.

However, compassion requires thought and in practice, the LCP appears to have been thoughtlessly used as a tick-box exercise. Someone’s final days, perhaps the most poignant of their life, cannot be managed on automatic. I want the LCP at its best, but I do not want it at the price of the LCP at its worst.

I hope that the end of the LCP can kick us into considering the spirit of the pathway, thinking intelligently and sensitively about death. But it will take more than newly considered guidelines and frameworks to ensure that. It requires a radical culture change. Our western capitalist societies tell us that we are invincible and we are immortal. God is dead – Live in the now! Tied in to this is the medical myth, that surgeons can excise any cancer, that doctors can cure any disease, and that death is always a failure. Death is not a failure, it comes to us all. Railing against it by assaulting the patient with heroic medical interventions is akin to a spoilt child’s tantrum, costing the dignity of the patient and the doctor.

With the wane of religion in the nineteenth century, the doctor replaced the priest at the deathbed. However, while the preacher offered spiritual solace to the patient and the family, the physician is still left wondering what to do. Extending a patient’s quantity of life by a fraction is not worth savaging their quality of life but for anxious family members at bedside, this argument competes with ‘do anything, do everything.’

What medicine hasn’t quite realised yet is that the act of dying is a group event. There is more than just the patient to consider. Including and supporting the family through such a pivotal event in their dynamic requires honest and sensitive communication. Communication is at the heart of the new recommendations. In that regard, communicating to one’s significant others about one’s intentions at the end of life is as vital as wishes regarding organ donation.

The LCP was a good start to intelligent and compassionate care of the dying. But even excepting the emotional blackmail of the press, abuse of the pathway cannot be excused. I don’t believe Baroness Neuberger’s recommendations will solve the broken culture of death we have but, along with the lessons of the LCP, they may be step in the right direction.

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