Liverpool Care Pathway

Fiona Bruce Excerpts

Tuesday 8th January 2013 Westminster Hall

[Fiona Bruce (Congleton) (Con)]

I congratulate my hon. Friend the Member for Montgomeryshire (Glyn Davies) not only on securing the debate but on the calm and measured way in which he introduced it—his was exactly the constructive tone in which we should discuss this concerning issue.

Last year, an 83-year-old widower was taken into hospital feeling very unwell. His eldest daughter visited him every day. No particular illness was diagnosed, but he was certainly weak and frail. After a few days, the daughter asked a nurse in the corridor, “How is he today?” Almost casually, the nurse said, “Oh, he’s not very well at all. He has not long to live. We are putting him on the Liverpool care pathway.” There was no discussion, no explanation, no consultation—just an announcement, a statement of fact, almost in passing. The daughter was shocked. As his eldest child, she thought, “Surely there should be more formality, more dignity, more of a clear process.” What gave her particular cause for concern was that her mother had become frail just two or so years earlier—admittedly after a brain tumour operation—and had been put on a regime of limited food and fluids. It had taken her weeks to pass away, which was agonising for her and heart-rending for the members of her family, as they waited and waited for their wife and mother to die. Again, there was no discussion or consultation with the daughter, although perhaps there was with the father. He was an elderly man in his 80s, and he was now lying in bed himself, about to be put on a similar regime.

After her mother died, the daughter felt a terrible guilt. Perhaps it had taken too long for her mother to die. Perhaps the daughter should have asked more questions. Perhaps she should not have let her mother suffer so much. With no medical background, however, she was left rather sad and confused. When the nurse announced that the hospital was putting her father on the Liverpool care pathway, the daughter, knowing a little more about it by this time, immediately contacted her sister, and the next day their father was moved to a nursing home. There, his needs were attended to in a positive and caring way. There, he did not die; in fact, he got better.

Now, well over six months later, that elderly man is very much alive. He is still being cared for. He is eating well, getting up when he wants to and resting when he does not want to get up. He enjoys visits from his family, although he does not enjoy it when his favourite football team loses in the last minute or so of a match, as happened last Saturday. He is listening to tapes of Sadler’s Wells opera company singing Gilbert and Sullivan, and he is joining in with “Songs of Praise”. He is having intelligent and considered discussions about his finances and looking forward to his 85th birthday. It is not a fantastic quality of life, but it is a life, and as he told his doctor in the nursing home, “I want to live.”

Minister, Mr Weir, concerned Members, I know all that is true, because the lady who passed away so distressingly was my mother, and the elderly man I have described is my father. I, their daughter, witnessed all those events first hand. In one sense, I am not sure I need to say much else to support the points that have been made, but the application of the LCP needs to be looked into.

[John Glen (Salisbury) (Con)]

My hon. Friend is making a powerful case, and it is obviously painful for her. Does she agree that there is a distinction between accepting the notion that a life must end and accepting that there is an inevitable time frame in which that life must end? We must not make premature assumptions about that period, so it is critical that there is a clear understanding of what the Liverpool pathway means and how it can affect the timings of an event we do not know the actual trajectory of.

[Fiona Bruce]

I thank my hon. Friend for that intelligent comment, and I will talk further about that.

I want to speak now as a vice-chair of the all-party group on dying well and the all-party pro-life group. Despite my personal experiences, I believe the main intent of the Liverpool care pathway is compassionate and good. It is fundamentally aimed at what is increasingly called a good death. When correctly administered, the principles behind it are those of good palliative care, and they are fully in accordance with the view, which I hold, that all life is God-given and should be allowed to run its course, without death being hastened through unnatural intervention.

[Jim Shannon]

I congratulate the hon. Lady on the passionate way in which she has dealt with this issue. Does she agree that it is important that those who work in the Liverpool pathway are highly skilled? If such care is left in the hands of those who are less skilled, there is a possibility that what could be termed voluntary euthanasia will take place. Does she agree that only highly skilled people should be involved in the Liverpool care pathway?

[Fiona Bruce]

I do, and this is where training is so important. Without the proper application of the Liverpool care pathway, death can be hastened, and that is not the intent of the pathway. Occasionally, even with correct application, it can be the unintended consequence—for example, through the use of narcotics to alleviate severe discomfort and facilitate a more peaceful passing.

I wholeheartedly welcome the Minister’s decision to hold an independent public inquiry into the LCP. I have met him, and I thank him for his open-minded, calm and reasoned approach and for the fact that he has had ears to hear concerns about the LCP. Without wishing to prejudge the terms of the inquiry, may I make the following suggestions for it to consider?

First, a number of pressures might subvert the proper implementation of the LCP, and I am grateful to Professor David Albert Jones of Oxford, who is an authority on this topic, for highlighting them. He says they are:

“the subjective character of judgments about how soon someone is going to die…the fact that the LCP may be initiated by people who are not senior clinicians familiar with the individual patient’s case and have not consulted with palliative care physicians… the influence of managerial pressures to reduce bed occupancy …reluctance to face the difficulties of continuing care of certain difficult patients…the euthanasiast outlook of some clinicians…the possibility of doctors or nurses regarding the LCP as a set of ‘tick boxes’…rather than assessing the needs of the patient…Other NHS organizational/staffing procedures or constraints”.

He adds:

“Research shows that care of the dying is poorest in the hospital setting”

in contrast to care in hospices, which I believe we all admire.

I also urge that the inquiry consider the following measures: that no patient should be placed on the LCP unless they are imminently, irreversibly and inevitably dying, which I understand to mean perhaps within 36 hours; no one should be placed on the LCP without its being discussed with a designated relative or carer; every patient placed on the LCP must be continuously monitored and reviewed by a multi-disciplinary team; documentation must be simplified and standardised, so that those implementing the LCP can easily follow the guidelines; training and supervision should be mandatory, as well as standardised and improved; non-clinical priorities in the use of the pathway must be eradicated and every patient must be treated solely according to their needs; payment for such care must be reconsidered; and the communication to relatives should be substantially improved.

I believe that, if it is well used, the LCP can improve standards of end-of-life care, especially in hospitals. It should promote better palliative care and support the kind of good death that we would all wish for ourselves and our loved ones. I sincerely hope that the independent inquiry will be a major step in facilitating that.