Care home briefing 126 – Liverpool Care Pathway: Rightly laid to rest?
The Liverpool Care Pathway for the Dying Patient (LCP) was developed with the intention that consistent good care is given to everyone thought to be dying within hours or within two or three days, whether they are in care homes, hospitals or in their own homes. It was based on a model of care successfully used in hospices and departed from what was seen as a tendency to over-actively treat people in an acute hospital setting where such treatment would not always prove a proportionate approach in view of the likely quality and quantity of life from which the patient could be expected to benefit. This approach would sometimes need to address whether withdrawal of treatment as well as decisions not to commence life sustaining treatment were appropriate given the circumstances of the patient.
An independent review of the LCP, chaired by Baroness Julia Neuberger, has criticised a number of aspects of the LCP and called for it to be replaced by an end of life care plan for each patient, backed up by condition specific good practice guidance, in the near future.
The LCP was never intended to be imposed upon people towards the end of their lives but, as with any treatment decision, was one that should be reached by involvement with the patient, taking into account their wishes at this sensitive time of their life, provided the person has mental capacity to make the decision. Similarly, where people lack capacity then there is a clear legal requirement to consult with relatives and carers, particularly to ascertain the likely wishes and values of the person with regard to their involvement in the LCP so that the decision can be made in that person’s best interests.
The review found evidence that relatives and carers were often not given the opportunity to ask questions and receive explanations of how decisions about treatment of people under the LCP have been made. The report states that “a significant number of relatives and carers do not feel that they were involved in discussions about the care plan, or even offered the chance to be involved….others were not told that their loved one was dying, which clearly contributed to their distress. It appears that a conversation with relatives or carers to explain the diagnosis, prognosis and uncertainties, clearly had simply not taken place.” This statement suggests that the use of the LCP has not always been applied in accordance with good practice. That does not mean that the LCP itself needs to be subjected to fundamental changes. If used appropriately, the LCP can provide a model of good practice for care of people towards the end of their lives; indeed, the report acknowledges “It would seem that when the LCP is operated by well-trained, well- resourced and sensitive clinical teams, it works well.”
The report also indicates that the term “Pathway” was misunderstood, being used by some healthcare staff as though it were a set of instructions and prescriptions, which was not its aim. An over rigid approach to any process without considering the underlying reasons and healthcare goals that are sought to be achieved will seldom be appropriate in a health care context. Nevertheless, this sometimes seems to have been at the heart of the problem of the LCP and the criticisms that have led to the Neuberger review.
When dealing with people at the end of life, it is always important for care homes and other healthcare bodies to have regard to a person’s capacity to make decisions and maintain good communication with the person and their family.
The need to respect the person’s dignity must always be a central consideration to steps taken by healthcare professionals. These factors were embodied in the LCP but it appears from the review that inappropriate implementation of the Pathway and poor training of the staff involved in its implementation, have resulted in the review and the recommendations made. The review has concluded that it is too late to salvage the LCP and that the new approach to end of life care planning should “ensure that guidance on care for the dying is properly understood and acted upon and tick-box exercises are confined to the waste paper basket forever.”
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This briefing is for guidance purposes only. RadcliffesLeBrasseur accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.