In Defence of the Liverpool Care Pathway

Liverpool Care Pathway:

In the past couple of weeks the Liverpool Care Pathway has come under attack from the press with a number of damaging and critical headlines, such as accusations that the pathway is being used to kill terminally ill patients. The Liverpool Care Pathway was first described in 2004 as a means for allowing the rapid discharge home of the dying patient. It is now used in hospitals throughout the UK and has transformed the way end of life care is achieved in the UK. It was recognised that many patients terminally ill patients were dying in acute hospital wards before they could be transferred to a hospice. Before the introduction of the pathway, there was a lack of common consensus about the best way to ensure that patients at the final stages of life are kept comfortable and that distress is alleviated. All of the negative publicity focused around the pathway appears to be that it hastens death through withdrawal of fluid and nutrition. The pathway does not preclude artificial hydration but seeks to prevent harmful interventions such as IV cannulation which will be harmful and not in the best interests of the patient. These headlines have consequences for doctors, patients, families and healthcare staff. Scaremongering could lead to fears from doctors about using appropriate analgesia and reluctance to use the LCP, leading to more painful deaths. The LCP does have the flexibility to be rescinded if clinically appropriate (occurs in approximately 4% of cases). Fortunately a number of organisations have rallied in support of the LCP following these allegations and having been involved in use of the LCP in hospital I too am in favour and hope that there is an end to the irresponsible journalism which has led to this situation.

Content Area Experts for Reviews:

A couple of weeks ago I was discussing with one of the dermatologists about which article or topic to include for a 'journal club' discussion. One option would be to present a 'meta-analysis' or systematic review of a clinical topic. The purpose of this is to draw together and summarise all of the available evidence. I was surprised to hear that in some cases an expert in a field is asked to write the publication, while in others it may be someone who has no expertise in the field who writes the paper. Systematic reviews often include experts as authors, however this may be create bias. No studies exist which look at whether is is harmful or helpful to have content area experts as authors. Potential benefits could be inside knowledge of unpublished trials. Potential harms include strong opinions due to prior personal experience and differences in conclusions between specialists in the same field. An article in the BMJ this week argues against using experts in systematic reviews and this is not something which I had thought about before now. I assumed that it was always area experts who wrote reviews but I can see the reasons why this may not always be beneficial.