LCP to be replaced with individual end of life care plans

Categories: Care.

The independent review of the LCP led by Baroness Julia Neuberger said that, while they support the principles of the LCP and agree that it can help patients have a dignified and pain-free death, there are too many cases where the LCP has been used as a ‘tick box’ exercise, failing to take account of a patient’s individual needs.

The government has agreed with the review’s recommendation that the LCP should be phased out and replaced with a more individual approach to end of life care for each patient.

Baroness Neuberger said: “There is no doubt that, in the right hands, the Liverpool Care Pathway supports people to experience high quality and compassionate care in the last hours and days of their life.

“But evidence given to the review has revealed too many serious cases of unacceptable care where the LCP has been incorrectly implemented. Examples include leaving patients without adequate nutrition, hydration and inappropriately sedated. This is not only awful for the patients, but it is deeply distressing to their relatives and carers.

“Caring for the dying must never again be practised as a tick box 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. Ultimately it is the way the LCP has been misused and misunderstood that has led to such great problems, along with it being simply too generic in its approach for the needs of some people. Sadly it is just too late to reverse this and turn the clock back to get it used properly by everybody. That is why we have recommended phasing out the LCP and replacing it with a more personalised and clinically sensitive approach.”

Care and support minister Norman Lamb commissioned the independent review in January in response to criticism of the use of the LCP by patients, families, carers and a number of clinicians. Today the review panel reported back, making a total of 44 recommendations around the Liverpool Care Pathway and end of life care.

Government response

The government has published an initial response to the review, agreeing that the LCP should be replaced with a personalised end of life care plan for each patient, backed up by condition-specific good practice guidance, agreed with a named senior clinician.

In a statement to the House of Commons, Norman Lamb also said that:

  • all NHS hospitals should undertake a clinical review, led by a senior clinician, of each patient who is currently being cared for using the LCP or similar to ensure that the care they are receiving is appropriate
  • all NHS hospitals should ensure that arrangements are put in place as soon as possible so every patient has a named senior clinician responsible for their care in their final hours and days of life
  • NHS England should work with CCGs to bring about an immediate end to local financial incentives for hospitals to promote a certain type of care for dying patients, including the LCP
  • the CQC will undertake a thematic review into end of life care and the three new chief inspectors – of hospitals, social care and general practice – will consider end of life care issues as they develop their new approaches to inspections
  • people who have a complaint about the care given to a dying patient on the LCP or similar will have access to an independent assessment of their case should they want it
  • all NHS hospitals should appoint a board member with responsibility for overseeing any complaints about end of life care and for reviewing how end of life care is provided.

The government will consider fully the recommendations of the review over the coming months and issue a full system-wide response to the review’s recommendations in the autumn.

Heather Richardson, national clinical lead at Help the Hospices highlighted concerns around the transition period: “We understand why the LCP is being phased out. However, we have concerns that this risks leaving a void in terms of how patients facing the end of life are cared for. We hope the transition to personalised care plans will be managed carefully and swiftly.”

Other recommendations

As has been highlighted many times before, the independent review also highlights the importance of communications skills and training for health and social care professionals around end of life care. The report recommends that doctors and nurses should be required to demonstrate proficiency in caring for the dying and that the Nursing and Midwifery Council should produce guidance for nurses caring for patients at end of life or who are dying – such guidance from the General Medical Council exists for doctors.

The review also calls for better funding for hospital palliative care teams, and for palliative care teams to combine to form integrated palliative care services, to enable better access to palliative care specialists outside office hours and at weekends, both in hospitals and in the community.

Heather added: “As this review highlights, providing high quality end of life care can never rely on pathways and procedures alone. It depends on a compassionate culture of care where patients are treated as individuals, where staff are fully trained and supported, underpinned by effective communication between healthcare professionals, patients and their families

“As the recent National Bereavement survey showed, hospices have an excellent track record in providing high quality, person-centred care for dying people. They have a huge contribution to make to radically improve standards across the healthcare sector. 

“This review must lead to stronger partnerships between hospitals and hospices to deliver high quality, dignified care for more people. Everyone should have access to the best possible care at the end of life, whoever they are, whatever their illness and wherever they are dying.”

The National Council for Palliative Care (NCPC) has also welcomed the review’s report. Eve Richardson, chief executive of NCPC and the Dying Matters Coalition, said: “We believe that its recommendations have the potential to make a real and much needed difference to the quality of care that people receive in the last days of their life.

“All those involved in end of life care must see this as a priority and provide ongoing training and support for staff to make this a reality – something the review is rightly very strong on. We also welcome the review’s conclusion that there needs to be a proper national conversation about dying, something that the Dying Matters Coalition which the National Council for Palliative Care leads is uniquely placed to be a key part of.”

Professor Mayur Lakhani, NCPC Chair and a practising GP, added: “We only have one chance to get it right for people who are dying, which is why this report is so important and welcome. Five years on from the End of Life Care Strategy, NHS England now has an important opportunity to set out plans for priority actions in end of life care, including arrangements to make sure that no one is left in limbo during the transition from the Liverpool Care Pathway to personalised end of life care plans.”

The LCP was recommended as a model of good care by the Department of Health’s End of Life Care Strategy in 2008, by the General Medical Council in 2010, and the National Institute for Health and Care Excellence in 2011. It was designed to be used as a means to manage a patient’s pain and distress when clinicians considered that they were in their last hours or days of life, and there was no appropriate reversible treatment for their condition.

Download ‘More care, less pathway: A review of the Liverpool Care Pathway‘ from the Department of Health website. The government’s response can also be found on the Department of Health website.

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