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 (‘LCP’) was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical 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. We also draw on the ‘boundary object’ concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. 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. 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.

Managing ethical uncertainty: implicit normativity and the sociology of ethics

“…In the case of LCP the potential uncertainties related to what had become ‘routine’ procedures in end‐of‐life care, which were managed through the LCP practice guidelines that had been trialled, developed and eventually endorsed nationally but which later became an arena of debate (first as a source of professional and academic contention and then through broadcast and social media advocacy and controversy); this then produced formal processes of review and new guidance to ‘re‐contain’ the uncertainties. (For those who are unfamiliar with LCP related debates, Seymour and Clark offer an excellent account of the ‘rise, demise and legacy’ of the LCP, along with the historical and ongoing axes of controversy around it).…”

Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y

“…The messages are also, commendably, not only directed towards doctors, as there is also information targeted to families and to other healthcare professionals, funders and managers. Of course, as experience with the Liverpool Care Pathway suggested, efforts will now be needed to ensure that the relevant messages are heard and heeded in practice [13]. In short, attention must now turn to translating the guidance into practice, by ensuring that those involved in these decisions – and particularly the responsible doctors – are suitably trained and supported going forward.…”

“…In their analysis of the demise of the Liverpool Care Pathway [12], Seymour and Clark have called 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’ [13]. Y might be considered such an intervention and certainly invites such an assessment.…”

Editorial

“…10 Similarly, in 2013 the LCP became the media scapegoat for many aspects of inadequate end-of-life care. 11–13 The Neuberger panel on the LCP 14 was rightly concerned with inappropriate prescribing and decisions that may have hastened death but, in recommending the removal of the LCP, they were unaware that unsafe practices, witnessed by Gosport, were being covered up long before the LCP was ever introduced. Second, the distinctions between safe and unsafe practise have been known for decades but confusion continues.…”