When care is poor, this must be investigated within the quality governance structure of the organisation that is providing that care. We need to learn, and apply that learning so that care can be continually improved.
A care pathway is a complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period. The sole purpose of our Liverpool Care Pathway for the Dying Patient (LCP) is to provide the best possible care for people in the last hours or days of their life.
It was designed as a hospital model in Liverpool in 1994 and was disseminated locally in 1997. It received national funding through the Beacon Programme in 2002 and became the core tool as part of End of Life Care Programme between 2004–07. It was also recommended in the DH End of Life Care Strategy in 2008 and then as Quality Markers in 2009. In 2011, it was recommended as evidence across nine of 16 quality statements in the NICE End of Life Care Quality Standard. An independent review of the implementation of the LCP took place in 2013, chaired by Baroness Neuberger. The LCP is, however, only as good as the people who are using it. The LCP is not an excuse for poor care.
Care supported by the LCP has previously been reviewed as part of three rounds of a National Audit in Hospitals in England 2006–2012. The vast majority of patients in the cohort of 13,623 patients across the three audits received good quality of care in the last hours or days of life.
In addition, learning organisations reviewed their position against a national benchmark and participated in national workshops. Key recommendations were outlined to drive up clinical excellence at each audit cycle. Round four is in process—a review of organisational data and infrastructure and clinical audit of expected deaths with or without the support of an LCP or equivalent. We also have for the first time a relative/carer bereavement questionnaire.
The Neuberger Review (NR), recognised the LCP as representing the right ethical principles for care of the dying. It stated that it provided good quality care when implemented properly. However, it also recommended that the name LCP should be abandoned, that within end of life care the term “pathway” should be avoided and that the use of the LCP should be replaced within the next 6–12 months by an end of life care plan for each patient backed up by condition-specific good practice guidance. This will be a system-wide strategic approach to improving care of the dying, clinical, education and research.
NHS England advice following the review was that where the LCP is being properly used it must not be stopped abruptly and that many people have experienced good end of life care using the LCP.
We must hold true to the fact that how we care for people who are dying is not just a matter of medical science but one of communication, compassion and humanity. It is a societal priority.
We have a huge opportunity to take our next big step to transform care for the dying if we will only come together to take it. A bad death that was avoidable is a poor outcome and must be seen as a failure.
We must take courage as ever from Cicely Saunders, who faced opposition in her work to transform care through hospices. If her vision is to be realised, we must integrate the model and values of hospice care into the mainstream NHS and deliver best care for dying patients regardless of place of care—something our patients not only deserve, but now demand.