The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

Abstract

Background : The Liverpool Care Pathway for the Dying Patient (‘the LCP’) was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review. The ensuing debate among clinicians polarised between ‘blaming’ of the LCP and regret at its removal. Employing the concept of ‘boundary objects’, we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods : We use primary and secondary sources in the public domain to assemble a critical and historical review. Results : The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP ‘scandal’ demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the ‘evidence’ required to underpin innovations in palliative care and became a conduit of discord about ‘good’ or ‘bad’ practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions : In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.

How Should End-of-Life Advance Care Planning Discussions Be Implemented According to Patients and Informal Carers? A Qualitative Review of Reviews

“…83 The limitations of this view in the context of end-of-life care were illustrated most starkly by the Liverpool Care Pathway, which failed in part because it came to be seen as a mechanistic checklist rather than a nuanced approach to care to be implemented with sensitivity. 89 There are continual warnings that ACP discussions should not be reduced to a tick-box exercise measured by blunt key performance indicators. 2 However, the extent to which nuanced, person-centered implementation of ACP that meets the diverse preferences of patients and carers will be achievable without health system change is unclear, 23 particularly when ACP implementation is largely evaluated by document completion.…”

“I want to die in my sleep”—how people think about death, choice, and control: findings from a Massive Open Online Course

“…Yet a closer analysis of the discourse surrounding death and dying presents a very complex picture, and the hesitancy of some people to address and discuss death and dying in some social contexts can be contrasted with the intensity of the advocacy and debate that boils over in others, for example on legalization of assisted dying, or with regard to public debate in the UK about the Liverpool Care Pathway (16)(17)(18)(19). In his survey of Kastenbaum's theory of the "death system" as applied to the USA, Corr concluded that rather than being simply death-denying, American attitudes demonstrate that denial and acceptance of death coexist (20), whilst a systematic review from the UK shows how attitudes vary greatly by age and health circumstances (21).…”

International review of national‐level guidelines on end‐of‐life care with focus on the withholding and withdrawing of artificial nutrition and hydration

“…Within the past 20 years, public consciousness has shifted to a point where palliative and EOL issues are being increasingly discussed publicly; the scrapping of the UK's Liverpool Care Pathway being a prime example. 11 Feedback from end users, such as physicians, caregivers and healthcare providers, might, therefore, be invaluable when crafting and fine-tuning these reactive guidelines in order to directly address critical points that are raised in legal and medical circles. Proactive guidelines, in contrast, might be too generic to precisely identify solutions or guidance on issues that have yet to be identified as important.…”