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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Under pressure at home, Donald Trump will struggle to deliver what Saudi Arabia wants

Above all, the Gulf states want stability. Can this beleaguered US president bring order?

There is a nervous energy around Riyadh. Fresh palm trees line the roads from the airport, punctuated by a wall of American flags and corporate slogans: “Together we prevail.” All the street lights are suddenly working.

The visit of any American president is always a lavish affair in Saudi Arabia, but there is an optimism to this visit that evaded the Obama years and even the recent visits of Theresa May and Angela Merkel.

Yet, there are two distinct parts to this trip – Trump’s first overseas engagement as president – that will determine its success. The first is relatively straightforward. Trump will sign huge defence contracts worth billions of dollars and offer trading opportunities that allow him to maintain his narrative of economic renewal for American businesses.

For the Saudis, too, these deals will fit into their ambitious project – known as Vision 2030 – to expand and diversify their economy away from its current dependence on oil revenues. Both parties are comfortable with this type of corporate and transactional government, enjoying the gaudy pomp and ceremony that comes with the signing of newly minted deals.

The more complicated aspects of the trip relate to its political dimensions. As the Middle East continues to convulse under the most significant turmoil to envelope it since the collapse of the Ottoman Empire, what Gulf leaders desperately want is the re-establishment of order. At its core, that is what will define Donald Trump’s visit to Saudi Arabia – and the Saudis are optimistic.

Their buoyancy is borne of shared regional interests, not least curbing Iranian influence. Ever since the Arab uprisings in 2011, Tehran has asserted itself across the Levant by organising hundreds of proxies to fight on its behalf in Syria and Iraq. Closer to home, too, the Gulf states accuse Iran of fomenting unrest within Shia communities in Saudi Arabia’s eastern provinces, in Bahrain, and in Yemen.

All of this has left the House of Saud feeling especially vulnerable. Having enjoyed an American security umbrella since the 1970s, Obama’s pursuit of the Iran deal left them feeling particularly exposed.

In part at least, this explains some of the Kingdom’s more frantic actions at home and abroad – including the execution of prominent Shia cleric, Sheikh Nimr al-Nimr, and the war in Yemen. Both are really about posturing to Iran: projecting power and demonstrating Saudi resolve.

Trump shares these concerns over Iranian influence, is prepared to look the other way on Saudi Arabia’s war in Yemen, and is deeply opposed to Obama’s nuclear deal. Riyadh believes he will restore the status quo and is encouraged by the direction of travel.

Just last month Trump commissioned a review of the Iran deal while the US Treasury imposed sanctions on two Iranian officials. Saudi Arabia also welcomed Trump’s decision to launch cruise missiles against a Syrian military base last month after Bashar al-Assad used chemical weapons in the town of Khan Sheikhoun.

These measures have been largely tokenistic, but their broader impact has been very significant. The Saudis, and their Gulf partners more generally, feel greatly reassured. This is an American presence in the region that is aligned to their interests, that they know well and can manage.

That is why Gulf states have rushed to embrace the new president ever since he first entered the Oval Office. Saudi Arabia’s deputy crown prince, Mohammed bin Salman (colloquially known simply as “MBS”), already visited him in Washington earlier this year. The Emiratis and others followed shortly afterwards.

A spokesman for Mohammed bin Salman later described the meeting with Trump as an “historical turning point” in relations between the two countries. A White House readout of the meeting baldly stated: “The President and the deputy crown prince noted the importance of confronting Iran's destabilising regional activities.”

Now that Trump is visiting them, the Saudis are hoping to broker an even broader series of engagements between the current administration and the Islamic world. To that end, they are bringing 24 different Muslim leaders to Saudi Arabia for this visit.

This is where Trump’s visit is likely to be fraught because he plans to deliver a major speech about Islam during his visit – a move that has seemingly no positives associated with it.

There is a lot of interest (and bemusement) from ordinary Saudis about what Trump will actually say. Most are willing to look beyond his divisive campaign rhetoric – he did, after all, declare “I think Islam hates us” – and listen to him in Riyadh. But what can he say?

Either he will indulge his audience by describing Islam as a great civilisation, thereby angering much of his political base; or he will stick to the deeply hostile rhetoric of his campaign.

There is, of course, room for an informed, careful, and nuanced speech to be made on the topic, but these are not adjectives commonly associated with Donald Trump. Indeed, the pressure is on.

He will be on the road for nine days at a time when pressure is building over the sacking of the former FBI director James Comey and the ongoing investigation into former national security advisor Michael Flynn’s contacts with Russia.

It is already being reported that Trump is not entirely enthusiastic about such a long overseas programme, but he is committed now. As with almost everything concerning his presidency, this extra pressure adds a wild air of unpredictability to what could happen.

Away from the lucrative deals and glad-handing, this will be the real standard by which to measure the success of Trump’s visit. For a relationship principally defined by its pursuit of stability, whether Trump can deliver what the Gulf really wants remains to be seen.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

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