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

A porter at Lewisham hospital, London, in 1981. (Getty.)
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Meet the remarkable British woman imprisoned for fighting against Isis

The treatment of Silhan Özçelik shows how confused British policy towards the Middle East has become. 

Last week, a British court sentenced a woman to prison for attempting to join fighters in the Middle East. Silhan Özçelik, an 18-year-old from Highbury, London was sentenced to 21 months for her part in “preparing terrorist acts” under the Terrorism Act 2006. The judge called her a “stupid, feckless and deeply dishonest young woman”.  What all of this misses out is the most extraordinary fact: that Özçelik was not convicted for going to fight for the Islamic State, but for the Kurdistan Workers’ Party – better known as the PKK, one of the only effective and consistent opponents of Isis since the war began.

Volunteering to fight in foreign wars – so long as they are long ago enough – is a celebrated tradition in Britain. In the late 1930s, while the Spanish Republic battled on against a fascist coup led by General Franco, tens of thousands of volunteers from all over the world went to fight for the International Brigades, including 2,500 from the UK. They included future celebrities such as writer George Orwell and actor James Robertson Justice, and commemorative plaques and memorials can now be seen all over the country

Like the International Brigade volunteers, Özçelik allegedly volunteered to fight for an embattled state facing military defeat at the hands of a far-right insurgency. The combat units she might have joined have been the subject of moving portraits in the Guardian and even praise on Fox News. The PKK is a secular socialist organisation, with a streak of libertarianism and its own feminist movements. But because of its military opposition to the often brutal Turkish treatment of the Kurds, the western powers list the PKK as a terrorist organisation; and would-be heroes like Silhan Özçelik are detained as criminals by the British state.

On one level, what Özçelik’s conviction represents is a change in how the state relates to ordinary citizens who fight. In 1936, the rise of fascism was something on our doorstep, which was opposed most fervently not by official western governments but by ordinary folk, dangerous far left subversives and free spirited writers who sailed to Spain – often in spite of their own governments. In today’s wars in the Middle East, the state is absolutely determined to maintain its monopoly on the right to sanction violence.

What Orwell and other volunteers understood was that while western governments might promote values like liberty and deplore the rise of tyranny, they were also duplicitous and unreliable when it came to prioritising the defeat of fascism over the narrow interests of nation and profit. Then as now, western governments were  deeply uneasy about the idea of ordinary people taking up arms and intervening in global affairs, or deciding – by force – who governs them. If the Terrorism Act 2006 had applied in 1936, Orwell would surely have been arrested at Dover and sent to prison.

More pressingly for the current situation, the persecution of the PKK should make you think twice about the motivations and outcomes for military intervention in Syria. Cameron is on a march to war, and, following the Paris attacks, much of the political establishment is now lining up to support him.

At the same time, our court system is imprisoning and persecuting young women who try to take up arms against Isis. It is doing so at the behest not of our own national security, which has never been threatened by the PKK, but that of Turkey. Turkey’s military is actively targeting Kurdish forces, and has recently stepped up these attacks. There is a wealth of evidence, not least its behaviour during the recent siege of Kobane, to suggest that Turkey – Britain’s only formal NATO ally in the region – is tacitly collaborating with Isis in an attempt to defeat both Assad and the Kurds.

As the government rushes to war in Syria, much of the media attention will focus on Jeremy Corbyn’s awkward task of holding his anti-war line while persuading his party and Shadow Cabinet not to split over the issue. Others will focus, rightly, on the complexity of the situation in the region and the question of who western air-strikes are really there to support: is it Assad, the murderous dictator whose regime has itself been linked to the rise of Isis; Turkey, which is seemingly focussed entirely on defeating Assad and the Kurds; or the soup of organisations – including the Al-Qaeda franchise in Syria – which constitute the anti-regime rebels?

But Özçelik’s conviction should also raise a more fundamental concern: that the contradictions and complications that we are so used to associating with the Middle East lie at the heart of British and western policy as well. If the British state persecutes, rather than supports, the few secular and progressive organisations in the region who are fighting Isis, whose interests is it really serving? And if we don’t trust those interests, how much trust can we really place in it to act on our behalf in Syria?

You can sign a petition calling for Silhan Özçelik’s release here, and a petition calling for the decriminalisation of the PKK here.