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NHS

Liverpool care pathway for dying patients to

be abolished after review
Review heard that regime meant to extend hospice- type care to hospitals led to
patients being drugged and deprived of fluids

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The Liverpool care pathway recommends that in some circumstances doctors withdraw treatment, food and water
from dying patients. Photograph: Montgomery Martin/Alamy

Sarah Boseley, health editor

Monday 15 July 2013
06.19 EDT

The Liverpool care pathway is to be abolished following a government-commissioned

review which heard that hospital staff wrongly interpreted its guidance for care of the
dying, leading to stories of patients who were drugged and deprived of fluids in their
last weeks of life.
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The government-commissioned review, headed by Lady Neuberger, found it was not the
pathway itself but poor training and sometimes a lack of compassion on the part of
nursing staff that was to blame, while junior doctors were expected to make life-anddeath decisions beyond their competence after hours and at weekends. The review says
individualised end-of-life care plans must be drawn up for every patient nearing that
stage.
"Caring for the dying must never again be practised as a tickbox exercise and each
patient must be cared for according to their individual needs and preferences, with
those of their relatives or carers being considered too," said Neuberger. "Ultimately it is
the way the LCP has been misused and misunderstood that had led to such great
problems."
She said it was too late to turn the clock back and
salvage the LCP, which was devised to try to extend

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the positive experiences of dying hospice patients into

the hospital setting. But in replacing it, the NHS must
make care of the dying part of its core business, she
said.
"What we have also exposed in this review is a range
of far wider, fundamental problems with care for the
dying a lack of care and compassion, unavailability
of suitably trained staff, no access to proper palliative
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care advice outside of 9-5, Monday to Friday."

The government confirmed it would phase out the LCP and said it would require all
hospitals to review the care of dying patients. Every such patient should in future have a
named senior doctor in charge of their care.
The care minister, Norman Lamb, said: "We hope the actions we have taken today will
reassure patients and their families that everyone coming to the end of their life is
getting the best possible care and that concerns are being dealt with swiftly.
"I have personally heard families describe staff slavishly following a process without
care or compassion and leaving people suffering at the end of their lives. This is
something we cannot allow to go on.
"People's final days should be as comfortable and dignified as possible. That is why
there is a place for thoughtful and careful end-of-life care that involves patients and
their families, but it is clear what we have now needs to be replaced so we can create a
better way of doing this."
The review listened to harrowing stories from families who had not been told their
loved one was expected to die and, in some cases, were shouted at by nurses for
attempting to give them a drink of water. Nursing staff had wrongly thought, under the
LCP guidance, that giving fluids was wrong. Some patients were put on the pathway and
treatment was withdrawn, only for them to make a recovery, albeit temporarily.
Communication was very poor and medical staff sometimes dodged painful discussions
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with patients and families, the review found.

The review strongly criticised the Nursing and
Midwifery Council, which unlike the General

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Medical Council, which regulates doctors offered no

guidance to nurses on the care of the dying. That must
change "as a matter of urgency", said Neuberger.
The NMC said it was already looking at standards of
conduct, performance and ethics of nurses, following
the Francis report into Mid-Staffordshire hospital. "In
light of the independent review into the Liverpool
care pathway the NMC must make sure that it is
issuing the right guidance for nurses and midwives,"
it said. "We will be working with relevant
stakeholders and studying the recommendations laid out in this review."
Jane Cummings, chief nursing officer for England, said: "I would like to reassure
everyone, particularly patients on the LCP and their families, that NHS England and the
NHS is passionate about ensuring that every patient receives the best possible care at
the end of their life. I have been a nurse for over 30 years and know how important care
at the end of life is for our loved ones. I say this both on a professional and a personal
level.
"The review and NHS England recognise the good principles of end of life care in the
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LCP, but there have been failings in the quality of care in some areas and this is never
acceptable. Caring for someone when they are dying is difficult and emotional even for
experienced healthcare professionals. But the NHS exists to provide personal and
compassionate care to patients and their loved ones when they most need it. Most of the
time we do get it right but we have to get it right for everybody. Issues such as poor
communication with relatives have nothing to do with any particular care plan. That is
just poor care and we don't want it in the NHS."
The review makes 44 recommendations, including the phasing out of the LCP over six to
12 months as individual care plans for the dying are brought in. It says that only senior
clinicians must make the decision to give end-of-life care, along with the healthcare
team, and that no decision must be taken out of hours unless there is a very good
reason.
It says there must be no incentive payments to hospitals to put patients on end-of-life
care, as occurred with the pathway. This was intended to offer encouragement to adopt
best practice but has been interpreted as payments to speed up patients' demise.

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View all comments >

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