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.)
Show Hide image

US election 2016: Trump threatens to deny democracy

When asked if he would accept the result of the election, the reality TV star said that he would have to “keep you in suspense.”

During this insane bad-acid-trip of an election campaign I have overused the phrase “let that sink in.”

There have been at least two dozen moments in the last 18 months which I have felt warranted a moment of horrified contemplation, a moment to sit and internalise the insanity of what is happening. That time a candidate for president brought up his penis size in a primary election debate, for one.

But there was a debate last night, and one of the protagonists threatened to undermine democracy in the United States of America, which throws the rest of this bizarre campaign into stark relief.

It was the third and final clash between an experienced if arguably politically problematic former senator and secretary of state – Hillary Clinton –  and a reality TV star accused of a growing number of sexual assaults – Donald Trump – but the tone and content of the debate mattered less than what the latter said at one key, illuminating moment.

That statement was this: asked if he would accept the result of the election, Donald Trump said that he was going to “look at it at the time,” and that he would have to “keep you in suspense.”

If your jaw just hit the floor, you have responded correctly. The candidate for the party of Lincoln, the party of Reagan, the party of Teddy Roosevelt, declined to uphold the most fundamental keystone of American democracy, which is to say, the peaceful transition of power.

Let that sink in. Let it sit; let it brew like hot, stewed tea.

This election has been historic in a vast number of ways, most important of which is that it will be, if current polling is to be believed, the election which will bring America's first female president to the White House, almost a century after women's suffrage was enabled by the 19th amendment to the constitution in August 1920.

If the last near-century for women in America has been a journey inexorably towards this moment, slowly chipping away at glass ceiling after glass ceiling, like the progression of some hellish video game, then Donald Trump is as fitting a final boss as it could be possible to imagine.

For Trump, this third and final debate in Las Vegas was do-or-die. His challenge was near-insurmountable for even a person with a first-class intellect, which Trump does not appear to possess, to face. First, he needed to speak in such a way as to defend his indefensible outbursts about women, not to mention the increasing number of allegations of actual sexual assault, claims backstopped by his own on-tape boasting of theoretical sexual assault released last month.

This, he failed to do, alleging instead that the growing number of sexual assault allegations against him are being fabricated and orchestrated by Clinton's campaign, which he called “sleazy”, at one point to actual laughs from the debate audience.

But he also needed to reach out to moderates, voters outside his base, voters who are not electrified by dog-whistle racism and lumbering misogyny. He tried to do this, using the Wikileaks dump of emails between Democratic party operators as a weapon. But that weapon is fatally limited, because ultimately not much is in the Wikileaks email dumps, really, except some slightly bitchy snark of the kind anyone on earth's emails would have and one hell of a recipe for risotto.

In the debate, moderator Chris Wallace admirably held the candidates to a largely more substantive, policy-driven debate than the two previous offerings – a fact made all the more notable considering that he was the only moderator of the three debates to come from Fox News – and predictably Trump floundered in the area of policy, choosing instead to fall back on old favourites like his lean-into-the-mic trick, which he used at one point to mutter “nasty woman” at Clinton like she'd just cut him off in traffic.

Trump was more subdued than the bombastic lummox to which the American media-consuming public have become accustomed, as if his new campaign manager Kellyanne Conway had dropped a couple of Xanax into his glass of water before he went on stage. He even successfully managed to grasp at some actual Republican talking-points – abortion, most notably – like a puppy who has been semi-successfully trained not to make a mess on the carpet.

He also hit his own favourite campaign notes, especially his opposition to the North American Free Trade Agreement (NAFTA) - but ultimately his intrinsic Donald Trumpiness couldn't stop itself from blazing through.

Remember the Republican primary debate when Trump refused to say that he would accept the party's nominee if it wasn't him? Well, he did it again: except this time, the pledge he refused to take wasn't an internal party matter; it was two centuries of American democratic tradition chucked out of the window like a spent cigarette. A pledge to potentially ignore the result of an election, given teeth by weeks of paranoiac ramblings about voter fraud and rigged election systems, setting America up for civil unrest and catastrophe, driving wedges into the cracks of a national discourse already strained with unprecedented polarisation and spite.

Let it, for what is hopefully just one final time, sink in.

Nicky Woolf is a writer for the Guardian based in the US. He tweets @NickyWoolf.