The Liverpool Care Pathway for the Dying Patient (LCP) is a care pathway which a patient can expect in the final days and hours of life, which also becomes a structured record of the actions and outcomes that develop. It aims to help doctors and nurses provide end-of-life care.
The Liverpool care pathway was developed between the Royal Liverpool hospital and the city's Marie Curie hospice in the late 1990s, to transfer practice in the dying phase from hospice to hospital. According to the National Mortality Statistics 2004, only 16% of cancer deaths and under 5% of non cancer deaths occur in a hospice.[1] The pathway was developed to try to provide the same level of nursing expertise at the end of life as during other treatments, regardless of the patient's chosen environment. The pathway document has an annual review by the multidisciplinary steering group who review the latest evidence and feedback from uses of the pathway to ensure that it remains up to date.
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The pathway aims to guide members of the multi-disciplinary team in matters relating to continuing medical treatment, discontinuation of treatment and comfort measures during the last days and hours. Its main emphasis is uniting professional support in the fields of physical treatment, psychological support, support for carers and spiritual care. The Liverpool Care Pathway is organised into sections ensuring that evaluation and care is continuous and consistent. Professionals using the Pathway need to ensure that both patient and carers understand that the structure and focus of care has now changed and the focus is now on care and comfort during the end stages of life.
The pathway was developed to act as a guide only. It is not intended to replace the skill and expertise of a health professional. As with other clinical pathways the patient's journey is an individual one, and an important part of the purpose of the pathway documents is to capture information on "variances", where due to circumstances or clinical judgment different actions have been taken, or different results unfolded. The pathway simply provides the practitioner with specific prompts to act upon, and aims to alleviate symptoms and to keep patient as comfortable as possible. Its lack of complexity, and ease of use makes the structure amenable to all health disciplines.
In the first stage of the pathway, the multi-professional team caring for the patient have to agree that all reversible causes for the patient's conditions have been considered and that the patient is in fact dying. The assessment then makes suggestions for what palliative care options to consider and whether non-essential treatments and medications should be discontinued. However, the pathway is not a "one-way-street" and if no further deterioration of the patient's condition occurs, pathway-based palliative care is halted and all previous treatments are resumed.[2] Currently this occurs for about 3% of patients put on the pathway.[3] The pathway recommends that the carers assess how well the patient can communicate and talk to their family, to check that they understand what is happening and see if their religious and spiritual needs are being addressed. The carers are also expected to discuss the plan of care with the patient and their family.
The programme also provides suggestions for treatments to manage any pain, agitation, respiratory tract secretions, nausea and vomiting, or shortness of breath (dyspnoea) that the patient may experience.[4] Staff are pre-authorised to give such interventions as required without further authorisation, usually by subcutaneous injection, so that symptoms can be addressed as soon as needed, without further delay.
Assessments of the effects and value of the pathway have been largely positive. A 2003 study published in the International Journal of Palliative Nursing found that nurses saw the pathway as having a generally positive effect on patients and their families.[5] A 2006 study published in the same journal found that, despite some "initial skepticism", the doctors and nurses who were interviewed saw the approach as having a valuable place in hospice care.[6] A multi-centre study was published in 2008 in the Journal of Palliative Medicine that found that nurses and relatives thought that the approach improved the management of patients' symptoms, but did not significantly improve communication.[7] The authors concluded that they "consider LCP use beneficial for the care for dying patients and their family."[7] A 2009 study published in Journal of Pain and Symptom Management studied the impact of the pathway on the end-of-life care of over three hundred patients and found that it produced a large decrease in the use of medication that might shorten life and increased patients' involvement in their medication and care.[8] A 2009 survey of 42 carers providing the pathway was published in the Journal of Palliative Medicine, it found that 84% were "highly satisfied" with the approach and that it enhanced patient dignity, symptom management and communication with families.[9]
Jonathan Potter, the director of the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians stated in 2009 that their audits showed that "where the Liverpool Care Pathway for the dying patient (LCP) is used, people are receiving high quality clinical care in the last hours and days of life".[10] The 2009 audit looked at end-of-life care in 155 hospitals, and examined the records of about 4,000 patients.
A 2008 article in The American Journal of Hospice and Palliative care criticised the Liverpool Pathway for its traditional approach and not taking an explicit position on the artificial hydration for critically ill patients.[11] A 2009 editorial in the Journal of Clinical Nursing welcomed the impetus towards providing improved care at the end of life and the more widespread use of integrated care pathways, but warned that much more research is needed to assess which of the several approaches that are in use is most effective.[12] In 2009 The Daily Telegraph wrote that the pathway has been blamed by some doctors for hastening the death of some mortally ill patients, and possibly masking signs that the patient is improving.[13] This story was criticised by the Association for Palliative Medicine and the anti-euthanasia charity Care Not Killing as inaccurate.[2][14] In contrast, The Times welcomed the pathway as an attempt to address patients' wishes and warned about "alarmist" press coverage of the scheme.[15] The Times also interviewed a palliative care nurse who uses the protocol, she stated that:[16]
In contrast to previous decades, where “almost every death was a crisis”, the pathway provides an equitable standard of care that involves regular checks to make sure patients are not suffering unduly or receiving inappropriate tests or drugs...We can’t avoid the inevitable, but you, me and anyone is entitled to the best care in the last hours of our lives. The LCP is one model that helps. It’s not always the answer, but it’s a step in the right direction.
Version 12 of the LCP was launched on 8 December 2009, after over two years of consultation. Amongst other revisions, it includes new decision making support on whether or not to start the LCP; highlighted guidance to review the appropriateness of continuing on the pathway at any time if concern is expressed by either the patient, a relative, or a team member; and new prompts to support decisions on artificial nutrition and hydration.[17][18] An editorial in the BMJ judged the new release did "much to tackle recent criticisms".[19]