Liverpool Care Pathway

Debate between Glyn Davies and Andrew Bridgen

Tuesday 8th January 2013 Westminster Hall

[Glyn Davies]

My hon. Friend makes a very important point about the need for training and expertise for all those who are responsible for putting people on the pathway and for looking after them when they are on it. I want to come to that later in my comments.

The negative coverage in our national media has probably increased awareness of the Liverpool care pathway. To that extent, I think that it has been a very good thing, but because I do not believe that the scale of the pathway is widely known, I think that it is right to say something about what the Liverpool care pathway is and what it is not in order to set out the context of the debate,. It is certainly not and must never be any form of “euthanasia by the back door”—a phrase that I have heard—nor is it a form of clinical treatment or even any specific type of care. It does not instruct doctors or nurses to provide this or that treatment. What it does is prompt them to consider whether certain treatments are appropriate in individual circumstances. It supports—it does not replace—clinical care. It is no more than a framework of good practice, backed up by training and education, to guide doctors, nurses and other health professionals towards delivering the high levels of palliative care that have been available in hospices for many years. It enables them to be transferred to hospitals, care homes and patients’ homes. It is about the appropriate way to look after a patient who is clearly dying through the last few days and hours of life.

Some other points should be made in this debate. The Liverpool care pathway does not recommend, as some have suggested, that dying patients should be deprived of food and water, although food and water may be withdrawn in individual cases if clinicians believe that that is the right step to take. The Liverpool care pathway does recommend to doctors and nurses that they explain to dying patients, or more often their next of kin, exactly what is happening and why. Secrecy forms no part of the Liverpool care pathway whatever.

It is also important to emphasise that there is nothing irreversible about being placed on the Liverpool care pathway.

[Andrew Bridgen (North West Leicestershire) (Con)]

Will my hon. Friend give way on that point?

[Glyn Davies]

On that point, I will, yes.

[Andrew Bridgen]

I thank my hon. Friend for calling this very important debate. I, too, share some of his concerns about the consistency with which the Liverpool care pathway is implemented across the country. I made some inquiries in the hospitals that serve my constituents, but information seemed to be lacking on the implementation of the care pathway. I am particularly concerned that patients placed on the pathway may have no opportunity to be taken off it if they improve. There are no figures on the number of patients for whom care has been reintroduced after being placed on the pathway. One of the hospitals told me, anecdotally, that no one there could remember anyone being taken off the pathway. I find that worrying.

[Glyn Davies]

My hon. Friend makes a very good point. Patients on the pathway should be monitored regularly, and if the patient shows signs of rallying, as does happen in a minority of cases, the treatment should be modified to support recovery. If that is not happening, the pathway is not being implemented properly. The Liverpool care pathway is not a pathway to death —a phrase I have seen used often, but which I think is unbelievably awful. It is a travesty of the truth to describe it as a form of euthanasia.

Why have we reached the point of huge public controversy, which has caused so much angst and fear? It has arisen from allegations—serious allegations, some of them from doctors and nurses—that the pattern of end-of-life care I have described has not been followed in some cases. There have been stories of dying patients being deprived of the food and water they needed and others being kept continuously sedated until they died; and of patients being placed on the pathway without consultation with them or their families, or to meet targets. The fear of that is especially shocking, and I hope the Minister will comment specifically on the issue of targets.

Let me look at some of the allegations in more detail. According to the Daily Mail in June last year,

“NHS doctors are prematurely ending the lives of thousands of elderly hospital patients because they are difficult to manage or to free up beds”.

The report is based on a presentation to the Royal Society of Medicine by Professor Patrick Pullicino, a consultant neurologist. He stated:

“The lack of evidence for initiating the Liverpool Care Pathway makes it an assisted death pathway rather than a care pathway.”

That is the debate being led by the Daily Mail. Professor Pullicino continued:

“Very likely many elderly patients who could live substantially longer are being killed by the LCP.”

Imagine how a frail elderly person entering hospital a few weeks after reading that would feel. Professor Pullicino added:

“Patients are frequently put on the pathway without a proper analysis of their condition.”

According to the Daily Telegraph, in September, a group of experts stated in a letter that

“dying patients…can…have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.”

The letter—again according to the Daily Telegraph—spoke of a “national crisis” in patient care, and

“a national wave of discontent…building up, as family and friends witness the denial of fluids and food to patients.”

According to the newspaper, some patients were wrongly being put on the pathway, which created a “self-fulfilling prophecy” that they would die. The report continued:

“Patients who are allowed to become dehydrated and then become confused can be wrongly put on this pathway”,

and,

“many doctors were not checking the progress of patients enough to notice improvement in their condition.”

Those are shockingly serious allegations. If they are true, urgent corrective action is needed.

There is another side to the equation, however. More than 20 respected organisations, including the Department of Health, Age UK, the Alzheimer’s Society, Macmillan Cancer Support, and the Royal Colleges of Physicians, General Practitioners and Nursing, have signed a declaration that

“Since the late 1990s, the Liverpool Care Pathway has been helping to spread elements of the hospice model of care into other healthcare settings”.

It mentions:

“Published misconceptions and often inaccurate information”—

referring, I think, to the stories in national newspapers I have quoted. Our task and the Minister’s is to reconcile the support of all those organisations for the Liverpool care pathway with the allegations made—in good faith, I am sure—by people who believe that the pathway is what they call a pathway to death.

Any tool is only as good as the workman who uses it. The declaration states clearly that the Liverpool care pathway

“Relies on staff being trained to have a thorough understanding of how to care for people who are in their last days or hours of life.”

We have to face the fact that, in most professions, there are instances of excellence and malpractice, and health care is no exception. It would be surprising if, when 130,000 people a year are dying on the Liverpool care pathway, there were no cases in which the pathway had been misapplied. That applies to every branch of medicine and, indeed, every occupation. There are good and less good doctors and nurses; there are well run and less well run hospitals; but to lay the blame at the door of the Liverpool care pathway is like tearing up “The Highway Code” because there are some bad drivers. Where there is bad practice and poor care, it should be rooted out and replaced with good care.

It seems to me that the review the Government recently launched provides an excellent opportunity to consider thoroughly all those issues. It is urgently needed. The review should call for any evidence of poor end-of-life care. We need the Minister to assure us this afternoon that the stories I have quoted will not simply be taken at face value, but will be investigated in detail, so that we can establish the scale of poor end-of-life care, and understand the causes and correct them.