Road to… Nowhere? ED Implications of the Liverpool Care Pathway Review

LCPIf you haven’t seen recent UK media coverage of the review of the Liverpool Care Pathway I have to wonder where you’ve been. Nevertheless, I really don’t want to get involved in the historical facts and opinions surrounding the pathway itself – I want to know what the recent review article means for me as an ED physician.

You can read the review here.

[learn_more caption=”What is the Liverpool Care Pathway?”]

You can read about the Liverpool Care Pathway (also known as the LCP) here. As the briefing paper says, it is an integrated care pathway designed to bring hospice care to dying patients in hospital and in the community, having recognised hospice care as best practice in promoting a dignified death. The LCP is used in some UK EDs to help structure end-of-life care priorities.

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[learn_more caption=”How does it work?”]

The pathway prompts healthcare professionals to consider whether a patient is dying and, if it is felt that the patient is in the terminal phase, contains trigger questions to help healthcare professionals to consider a shift in priorities to focus on the patient’s needs.

What does that actually mean? Well, this will differ from patient to patient but may involve providing pain relief or sedation for terminal agitation, treatment for respiratory secretions, nausea and vomiting, and cessation of medications which are no longer necessary (often preventative medications such as statins or aspirin).

The pathway sets out dosing advice for medications with which doctors may not be immediately familiar but is not a prescriptive document; each section must be completed individually.

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[learn_more caption=”What does the review say?”]

“…In the right hands, the Liverpool Care Pathway can provide a model of good practice for the last days or hours of life for many patients. The ambition to transpose hospice-like standards of care into the hospital setting is admirable: before the widespread introduction of the LCP into hospitals, the care that patients received was variable and there were many examples of poor care. But it is clear that, in the wrong hands, the LCP has been used as an excuse for poor quality care.”

“…The Review panel strongly recommends that use of the Liverpool Care Pathway be replaced within the next six to 12 months by an end of life care plan for each patient, backed up by condition-specific good practice guidance.”

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[learn_more caption=”What does this mean for dying patients in the ED?”]

For my practice – actually, not a great deal.

Why?

Because I routinely use the pathway’s principles of care but adapt the practicalities of care to the needs of the patient in front of me.

I rarely use the formal paperwork for the LCP but I frequently talk to patients about what they want; where they would like to be, what treatments they don’t want to have. Non-invasive ventilation is ever unpopular 🙂

Often I have conversations with relatives where we agree together what their relative would want (if they are not able to express it themselves) and how we can best address their current needs. Sometimes this means I prescribe doses of anti-emetics as needed on a drug chart instead of in ED paperwork. Often I prescribe “as needed” analgesia.

Sometimes, we agree that we will continue to give fluids and antibiotics through that cannula which took three attempts to site – but if it stops working, we won’t start stabbing away at those bruised arms if the treatment we have already given through that drip hasn’t made any difference.

This is the practicality of the LCP – a guideline to prompt us to think about what we are doing. The resus recipe (IV access, bloods, CXR, antibiotics, refer medics) is easy but it’s not always right.

We don’t get our prognostication right every time – I am always careful to explain to relatives that it is very difficult to predict how patients will respond to treatment; some may respond and get better, some improve for a short period to deteriorate again, and some do not respond to treatment at all – but I can count on one hand the number of times the conversation has gone “wrong”. When it comes to it, it’s about how you express your desire to do the best for your patient. That’s ultimately what the patient and their relatives want too.

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[learn_more caption=”Is there a bottom line here?”] There is almost certainly more to come on the subject of end-of-life care, but ED practitioners may not feel much change. We won’t call what we do the LCP any more – the review essentially wants good quality end-of-life care, supported by senior clinicians, with a different name.

It’s easy enough to stop using the phrase “Liverpool Care Pathway” and instead talk about “looking after people properly”, “keeping patients comfortable” and “striving for dignity in death while minimising distress”.

And I bet you do all these things already. [/learn_more]

Also see: An Easter message: let’s talk about dying

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