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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Qatar is determined to stand up to its Gulf neighbours – but at what price?

The tensions date back to the maverick rule of Hamad bin Khalifa al-Thani.

For much of the two decades plus since Hamad bin Khalifa al-Thani deposed his father to become emir of Qatar, the tiny gas-rich emirate’s foreign policy has been built around two guiding principles: differentiating itself from its Gulf neighbours, particularly the regional Arab hegemon Saudi Arabia, and insulating itself from Saudi influence. Over the past two months, Hamad’s strategy has been put to the test. From a Qatari perspective it has paid off. But at what cost?

When Hamad became emir in 1995, he instantly ruffled feathers. He walked out of a meeting of the Gulf Cooperation Council (GCC) because, he believed, Saudi Arabia had jumped the queue to take on the council’s rotating presidency. Hamad also spurned the offer of mediation from the then-President of the United Arab Emirates (UAE) Sheikh Zayed bin Sultan al-Nahyan. This further angered his neighbours, who began making public overtures towards Khalifa, the deposed emir, who was soon in Abu Dhabi and promising a swift return to power in Doha. In 1996, Hamad accused Saudi Arabia, Bahrain and the UAE of sponsoring a coup attempt against Hamad, bringing GCC relations to a then-all-time low.

Read more: How to end the stand off in the Gulf

The spat was ultimately resolved, as were a series of border and territory disputes between Qatar, Bahrain and Saudi Arabia, but mistrust of Hamad - and vice versa - has lingered ever since. As crown prince, Hamad and his key ally Hamad bin Jassim al-Thani had pushed for Qatar to throw off what they saw as the yoke of Saudi dominance in the Gulf, in part by developing the country’s huge gas reserves and exporting liquefied gas on ships, rather than through pipelines that ran through neighbouring states. Doing so freed Qatar from the influence of the Organisation of Petroleum Exporting Countries, the Saudi-dominated oil cartel which sets oil output levels and tries to set oil market prices, but does not have a say on gas production. It also helped the country avoid entering into a mooted GCC-wide gas network that would have seen its neighbours control transport links or dictate the – likely low - price for its main natural resource.

Qatar has since become the richest per-capita country in the world. Hamad invested the windfall in soft power, building the Al Jazeera media network and spending freely in developing and conflict-afflicted countries. By developing its gas resources in joint venture with Western firms including the US’s Exxon Mobil and France’s Total, it has created important relationships with senior officials in those countries. Its decision to house a major US military base – the Al Udeid facility is the largest American base in the Middle East, and is crucial to US military efforts in Iraq, Syria and Afghanistan – Qatar has made itself an important partner to a major Western power. Turkey, a regional ally, has also built a military base in Qatar.

Hamad and Hamad bin Jassem also worked to place themselves as mediators in a range of conflicts in Sudan, Somalia and Yemen and beyond, and as a base for exiled dissidents. They sold Qatar as a promoter of dialogue and tolerance, although there is an open question as to whether this attitude extends to Qatar itself. The country, much like its neighbours, is still an absolute monarchy in which there is little in the way of real free speech or space for dissent. Qatar’s critics, meanwhile, argue that its claims to promote human rights and free speech really boil down to an attempt to empower the Muslim Brotherhood. Doha funded Muslim Brotherhood-linked groups during and after the Arab Spring uprisings of 2011, while Al Jazeera cheerleaded protest movements, much to the chagrin of Qatar's neighbours. They see the group as a powerful threat to their dynastic rule and argue that the Brotherhood is a “gateway drug” to jihadism. In 2013,  after Western allies became concerned that Qatar had inadvertently funded jihadist groups in Libya and Syria, Hamad was forced to step down in favour of his son Tamim. Soon, Tamim came under pressure from Qatar’s neighbours to rein in his father’s maverick policies.

Today, Qatar has a high degree of economic independence from its neighbours and powerful friends abroad. Officials in Doha reckon that this should be enough to stave off the advances of the “Quad” of countries – Bahrain, Egypt, Saudi Arabia and the UAE - that have been trying to isolate the emirate since June. They have been doing this by cutting off diplomatic and trade ties, and labelling Qatar a state sponsor of terror groups. For the Quad, the aim is to end what it sees as Qatar’s disruptive presence in the region. For officials in Doha, it is an attempt to impinge on the country’s sovereignty and turn Qatar into a vassal state. So far, the strategies put in place by Hamad to insure Qatar from regional pressure have paid off. But how long can this last?

Qatar’s Western allies are also Saudi Arabia and the UAE’s. Thus far, they have been paralysed by indecision over the standoff, and after failed mediation attempts have decided to leave the task of resolving what they see as a “family affair” to the Emir of Kuwait, Sabah al-Sabah. As long as the Quad limits itself to economic and diplomatic attacks, they are unlikely to pick a side. It is by no means clear they would side with Doha in a pinch (President Trump, in defiance of the US foreign policy establishment, has made his feelings clear on the issue). Although accusations that Qatar sponsors extremists are no more true than similar charges made against Saudi Arabia or Kuwait – sympathetic local populations and lax banking regulations tend to be the major issue – few Western politicians want to be seen backing an ally, that in turn many diplomats see as backing multiple horses.

Meanwhile, although Qatar is a rich country, the standoff is hurting its economy. Reuters reports that there are concerns that the country’s massive $300bn in foreign assets might not be as liquid as many assume. This means that although it has plenty of money abroad, it could face a cash crunch if the crisis rolls on.

Qatar might not like its neighbours, but it can’t simply cut itself off from the Gulf and float on to a new location. At some point, there will need to be a resolution. But with the Quad seemingly happy with the current status quo, and Hamad’s insurance policies paying off, a solution looks some way off.