An audit of Care of the Dying covering nearly 4,000 terminally ill patients in over 150 hospitals in England has concluded that use of the Liverpool Care Pathway (LCP) is resulting in high quality care for those who are in the very last hours and days of life. The audit, which was conducted by the Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians and the results of which were made public yesterday, underlines the value of the LCP in providing a framework for decision-making by doctors treating imminently dying patients.

The audit does not support criticisms of the LCP that have appeared recently in the media - namely, that patients who are managed in accordance with the Pathway's guidelines are being heavily sedated until they die or that the LCP is promoting a 'tick box' approach in which doctors sometimes fail to spot where patients show signs of recovery. The audit reveals that two thirds of the 3,893 patients whose deaths were assessed needed no continuous infusion of medication in the last 24 hours of life to control distress caused by restless or agitation and that, of those who did require such infusions, all but 4% needed only low doses. Unlike practices in other countries, such as the Netherlands where deep continuous sedation until death is administered according to a protocol, palliative care physicians in Britain have the skills to ensure that the overwhelming majority of terminally ill patients are able to die peacefully and without any significant sedation.

Commenting on the Audit, Dr Peter Saunders, Director of Care Not Killing, said: "This audit of LCP practice in some three quarters of hospitals in England is reassuring. It confirms that deep sedation of terminally ill patients is rare in Britain and that recent suggestions of its widespread use under the LCP are unfounded. It also underlines that any trusts prescribing relatively high doses of sedatives regularly to dying patients 'need to review their practice'". Professor John Ellershaw, Director of the Marie Curie Palliative Care Institute, confirmed this. "The Liverpool Care Pathway", he said, "does not endorse continuous deep sedation nor, as has been misreported in some places, the removal from dying patients of beneficial medication".

Commenting on suggestions that doctors following the LCP's guidelines who do not have specialist knowledge of end of life medicine may sometimes fail to recognise signs of a recovery, Dr Saunders said: "Any tool is only as good as the workman who uses it. It is important to remember, however, that clinical decisions in end of life care are not made in isolation and that palliative care hospital support teams are available throughout the country to support other specialities in this work. These teams include physicians who also practice in the local hospice or palliative care unit". He added: "There is nonetheless a need for continuing education of health care professionals at all levels in all aspects of modern palliative care, including diagnosing correctly that patients are imminently dying and detecting reversible causes of deterioration in patients in advanced illness. The new version of the pathway has addressed past ambiguities in interpretation and has been warmly welcomed by the Patients' Association but we do need to continue close monitoring to ensure that it is being used appropriately."

Dr Bill Noble, President of the Association for Palliative Medicine, has also commented on recent press reports on the LCP:

"The Liverpool Care Pathway is not a one-way street and, when further deterioration does not occur, it is common practice to take the patient off the Pathway and re-institute previous treatment. The care pathway approach is now commonly used to aid the work of many specialities throughout the health service. It does not replace clinical judgement, but acts as a prompt to assist clinical teams to ensure that every patient gets adequate attention to every aspect of their care. Clinical pathways are useful in auditing practice and developing services. It is possible to misuse any clinical tool, but our experience of working with colleagues in hospitals and the community is that, with adequate training and support, it is used appropriately".


End-of-life palliative care needs to start earlier (The Times, 17th September 2009, Dr Bill Noble)

Liverpool hospitals death 'pathway' manager describes her job (The Times 14th September 2009, David Rose, Health Correspondent)

Briefing: Fatal decisions (The Sunday Times, 6th September 2009, Helen Brooks)

The Liverpool Care Pathway need not be a one-way street to death (Telegraph, 5th September 2009)

Liverpool Care Pathway

The draft version of the Liverpool Care Pathway Version 12 is now available, for review and comment. The final version will be launched at the LCP Conference 25th November 2009.

The most recent version of the Liverpool Care Pathway (version 11) is presented in direct relation to the four following categories:

Care homes

2008/2009 report by
Marie Curie Palliative Care Institute Liverpool (MCPCIL) on The Liverpool Care Pathway

'This audit is a significant step towards the development of a national benchmark across all other health sectors'

Prepared by the Marie Curie Palliative Care Institute Liverpool (MCPCIL) in collaboration with the Clinical Standards Department of the Royal College of Physicians (RCP), this 2008/2009 report is supported by Marie Curie Cancer Care & Department of Health End of Life Care Programme.

Note for Editors

· The Marie Curie Palliative Care Institute Liverpool (MCPCIL) has pioneered the implementation of the LCP. This programme is recognised nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and to provide support to their relatives/carers. This National Audit is unique in the world in both size and scope collecting data from 155 Hospitals representing nearly three quarters of hospitals in England and in a parallel pilot audit undertaken in Northern Ireland hospitals.

· The Royal College of Physicians of London is responsible for standards of postgraduate training and education for physicians. It provides a huge range of services to its 20,000 Members and Fellows and other medical professionals. These include delivering examinations, training courses, continuous professional development and conferences; undertaking clinical audits; publishing newsletters, guidelines and books through to maintaining the College's historical collections. It also leads medical debate, and lobbies and advises government and other decision-makers on behalf of its members.

· More than half of all deaths in England occur in the hospital sector (ONS, 2005). So high quality personal and nursing care is essential for the comfort of the dying patient and for the hospitals to provide appropriate support to carers.

· The Liverpool Care Pathway for the Dying Patient (LCP) has been recommended for use as a template of best practice in the last hours and days of life in UK National policy (DH 2006, 2008) and more recently in the National End of Life Care Strategy: Quality Markers and Measures for End of Life Care (2009). The first National Care of the Dying Audit in Hospitals (NCDAH) of 2672 patients was undertaken in 2006/2007 based on the standards of care within the LCP.

· The second National Care of the Dying Audit Hospitals (NCDAH) includes 3893 Patients whose care was delivered supported by the LCP. This cohort represented 114 Hospital Trusts across all 10 Strategic Health Authorities. A prospective audit design was used to gather LCP data from up to 30 consecutive deaths in each of the participating hospitals between 1st October 2008 and 31st December 2008.

· Care Not Killing is a UK-based alliance of individuals and organisations which brings together disability and human rights organisations, healthcare and palliative care groups, and faith-based bodies, with the aims of:

1. promoting more and better palliative care;

2. ensuring that existing laws against euthanasia and assisted suicide are not weakened or repealed during the lifetime of the current Parliament;

3. influencing the balance of public opinion further against any weakening of the law.

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