Where did the hysteria over the Liverpool Care Pathway originate?

We need to talk openly about dying.

As a staunch and outspoken supporter and defender of the Liverpool Care Pathway I have recently been contemplating a great deal why the whole furore started. We have been using the pathway for years so why now? I seem to recollect that a few years ago the approach was criticised by some eminent doctors in the national press but after a couple of articles and a little disquiet the debate simmered down and we as practising clinicians continued to use what is considered the framework for best practice when delivering end of life care. The issue certainly was not debated in every mainstream current affairs media outlet and politicised with numerous relatives stepping out into the arena to tell their own horror stories.

So what has happened in those few years? The LCP itself has not really changed. Perhaps the document has been developed a little but the fundamental principles of care remain the same. Maybe it is society’s expectations that have changed. There remains a huge taboo surrounding discussing death and dying openly despite the work of fantastic organisations such as Dying Matters and Good Life Good Death Good Grief. Because of this taboo, acceptance that all illness cannot be cured is sometimes limited and this can lead to huge friction between health professionals and devastated relatives when we reach the end of the line in terms of active treatment of a condition.

Perhaps it is because the press love to indulge in a little of what I glibly call "doctor bashing" and feel that we as doctors must have some sinister, ulterior motives underlying our work in end of life care. By sowing these seeds of doubt that we as a profession should not be trusted and preying on society’s deep seated fears about dying news stories that sell papers are created. There is also perhaps a perception more and more that everything done in the NHS is underpinned by monetary factors, bed pressures and lack of resources and that these issues motivate us as doctors rather than our patient’s best interests, is which something I find very sad as I go to work primarily to look after people.

Perhaps the pressure on the NHS in recent years has led to such a time-deprived environment in some hospitals that communication has suffered as a result and that is why families have not perhaps felt as cared for and as informed as they should have. This may have led to misunderstandings about the intentions of using an LCP approach as communicating in this area especially about the uncertainties surrounding dying is complex and takes time.

So for whatever reason the sparks of the story did ignite and the irresponsible handling by some of the media has left us as clinicians in a hugely difficult and worrying place. As a doctor I would hope that the relationship I have with my patients and their families is based on a solid foundation of trust; a trust that I am there solely to act in their best interests and to care for them. As a patient myself I trust my own GP and oncologist implicitly. But when the press and sometimes the politicians start to undermine this trust then we are left in an extremely worrying and dark situation.

How do we fix it? I do not believe the problem itself has anything to do with the actual LCP. I think the solution is really very simple and yet difficult to achieve. When someone is diagnosed with a condition that is going to limit their lifespan such as heart failure, dementia, metastatic cancer or MND for example I believe early, open and honest discussion about prognosis is a necessity. This allows the patient choice and some degree of control over what will happen in their life. Investment in Palliative Care services so that these highly skilled professionals can be involved early on in life limiting illnesses would undoubtedly help in these discussions. This would replace the current scenario which often arises and is best illustrated by using cancer care as an example. A patient is diagnosed with a metastatic cancer. The Oncologists treat them. Eventually the Oncologist’s treatments become futile and their care is then handed over to the Palliative Care team at this point, who are then only involved for relatively little time in that patient’s journey. In my model the Palliative Care practitioner would be in the clinic when the patient is first diagnosed and work in partnership all the way with that patient. I am reminded of a quote from Dame Cicely Saunders, the founder of the hospice movement, "you matter because you are you, and you matter until the last moment of your life. We will do all we can, not only to help you die peacefully, but also to live until you die."

Therefore when we reach the point where the LCP becomes appropriate we would have patients and families who are well informed and hopefully accepting of their situation enabling the partnership work to continue seamlessly into the final hours and days. Because of the openness agenda the wishes of the patient would be known and could have been planned for enabling us to achieve that Holy Grail "a good death".

So it is not fancy technologies or complicated research that is going to fix the problem. It is quite simply some good quality talking and a culture and environment that allows this to happen. One of the reasons I have been so open about my own dying both in public and in private with those I love is that I believe openness is inextricably linked to achieving "a good death" and perhaps more importantly "good grief" for those left behind.

Dr Kate Granger blogs at http://drkategranger.wordpress.com/

A porter at Lewisham hospital, London, in 1981. (Getty.)
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Why Podemos will defeat the Spanish Socialists

A new alliance on the Spanish Left will be stronger than the sum of its parts.

On Saturday morning, on a palm-tree lined promenade in the small city of Badalona in eastern Catalonia, a 38-year-old woman named Mar García Puig fanned herself with her speaking notes after taking her turn on the stage.

Until six months ago, Puig was a literary editor with no professional experience in politics apart from attending demonstrations and rallies. Then, in December, her life was transformed twice over. In the national election, she won a parliamentary seat for En Comú Podem, the Catalan regional ally of the anti-austerity party Podemos. Four hours after she learned of her victory, Puig gave birth to twins.

Fortunately Puig’s husband, who is a teacher, was able to take paternity leave so that she could take up her seat. In parliament, Puig “felt like an alien”, she told me over coffee. As it turned out, she had to give up her seat prematurely anyway – along with all the other Spanish MPs – when repeated attempts to form a government failed. So now, in the lead-up to Spain’s first repeat election of the modern era, to be held on 26 June, Puig was on the campaign trail once more in a drive to win a parliamentary seat.

The December general election was as historic as it was inconclusive, ushering in a novel political era in Spain and leaving the country with the most fragmented parliament in its history. Fed up with corruption, austerity and a weak recovery from the global financial crisis, voters punished the mainstream parties, ending the 40-year dominance of the conservative Partido Popular (People’s Party) and the centre-left PSOE (Spanish Socialist Workers’ Party), which have held power since the death of General Franco. Neither group was able to win an absolute majority as new parties from both ends of the political spectrum garnered support from disenchanted voters.

On the left, Podemos, which was only founded in March 2014 by the ponytailed political scientist Pablo Iglesias, won 20 per cent of the vote. Ciudadanos (Citizens), formed in Catalonia a decade ago and occupying the centre left or centre right, depending on which analyst you talk to, secured a 14 per cent share.

Despite having four months to form a coalition government, the two biggest political parties could not reach a deal. The People’s Party, which had implemented a harsh austerity package over the past five years, recorded its worst electoral performance since 1989, losing 16 percentage points. It still won the most votes, however, and Prime Minister Mariano Rajoy was the first leader to be asked by King Felipe VI to form a government.

By the end of January, Rajoy conceded defeat after the PSOE refused to join his “grand coalition”. The Socialists then failed in their own attempt to form a government, leading the king to dissolve parliament and call a fresh election.

Despite the inconvenience of having to campaign nationwide once again – and being away from her twins – Mar García Puig’s enthusiasm for her new career is undiminished. “In Spain there is a window of opportunity,” she said. “There is a receptiveness to politics that there wasn’t before.”

When the repeat elections were called, some questioned whether Podemos and its regional allies could mobilise its supporters to the same extent as in December. Yet Puig believes that the party’s appeal has grown further in the six months that the country has been without a government. “We are still new and Podemos has this freshness – it can still make people join,” she told me.

The following day, as the church bells rang at noon in the Basque city of Bilbao, crowds gathered for another rally. For protection against the sun, Podemos supporters had covered their heads with purple triangular paper hats displaying the party name as it will appear on the ballot paper: Unidos Podemos, or “United We Can”.

In May, Podemos entered into an alliance with Izquierda Unida (United Left), the radical left-wing party that includes the Communist Party of Spain, and which won 3 per cent of the vote in December. Izquierda Unida is headed by Alberto Garzón, a 30-year-old Marxist economist who, according to a poll by the state-run CIS research institute, is the most highly rated party leader in Spain. Unlike Podemos’s Iglesias, who can fire up a crowd and is seen by some as divisive, Garzón is a calm and articulate politician who appeals to disaffected voters.

Nagua Alba, who at 26 is Podemos’s youngest MP, said the new alliance would be stronger than the sum of its parts, because Spain’s voting system punishes smaller parties when it comes to allocating seats in parliament. “It [the alliance] will attract all those people that aren’t convinced yet. It shows we can all work together,” Alba said.

As part of the agreement with Podemos, Izquierda Unida has agreed to drop its demands for a programme of renationalisation and withdrawing Spain from Nato. The alliance is campaigning on a platform of reversing Rajoy’s labour reforms, removing the national debt ceiling, opposing the TTIP trade deal, and increasing the minimum wage to €900 a month. A Unidos Podemos government would attempt to move the EU’s economic policy away from austerity and towards a more expansionist stance, joining a broader effort that involves Greece, Italy and Portugal. It is also committed to offering the Catalans a referendum on independence, a move that the mainstream parties strongly oppose.

The latest polls suggest that Unidos Podemos will become Spain’s second-biggest party, with 26 per cent of the vote, behind Rajoy’s Popular Party. The Socialist Party looks poised to fall into third place, with 21 per cent, and Ciudadanos is expected to hold its 14 per cent share. If the polls are accurate, the PSOE will face a difficult choice that highlights how far its stock has fallen. It can choose to enter as a junior partner into a coalition with the insurgent left, which has politically outmanoeuvred it. Or it could decide to prop up a Partido Popular-led right-wing coalition, serving as a constraint on power. 

This article first appeared in the 23 June 2016 issue of the New Statesman, Divided Britain