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.)
Photo: Getty
Show Hide image

When Donald Trump talks, remember that Donald Trump almost always lies

Anyone getting excited about a trade deal between the United States and the United Kingdom should pay more attention to what Trump does, not what he says. 

Celebrations all round at the Times, which has bagged the first British newspaper interview with President-Elect Donald Trump.

Here are the headlines: he’s said that the EU has become a “vehicle for Germany”, that Nato is “obsolete” as it hasn’t focused on the big issue of the time (tackling Islamic terrorism), and that he expects that other countries will join the United Kingdom in leaving the European Union.

But what will trigger celebrations outside of the News Building is that Trump has this to say about a US-UK trade deal: his administration will ““work very hard to get it done quickly and done properly”. Time for champagne at Downing Street?

When reading or listening to an interview with Donald Trump, don’t forget that this is the man who has lied about, among other things, who really paid for gifts to charity on Celebrity Apprentice, being named Michigan’s Man of the Year in 2011, and making Mexico pay for a border wall between it and the United States. So take everything he promises with an ocean’s worth of salt, and instead look at what he does.   

Remember that in the same interview, the President-Elect threatened to hit BMW with sanctions over its decision to put a factory in Mexico, not the United States. More importantly, look at the people he is appointing to fill key trade posts: they are not free traders or anything like it. Anyone waiting for a Trump-backed trade deal that is “good for the UK” will wait a long time.

And as chess champion turned Putin-critic-in-chief Garry Kasparov notes on Twitter, it’s worth noting that Trump’s remarks on foreign affairs are near-identical to Putin’s. The idea that Nato’s traditional purpose is obsolete and that the focus should be on Islamic terrorism, meanwhile, will come as a shock to the Baltic states, and indeed, to the 650 British soldiers who have been sent to Estonia and Poland as part of a Nato deployment to deter Russian aggression against those countries.

All in all, I wouldn’t start declaring the new President is good news for the UK just yet.

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.