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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French voters face a choice: Thatcherism or fascism

Today's Morning Call. 

Francois Fillon has been handed the task of saving France from a Marine Le Pen presidency and, by extension, the European Union from collapse, after a landslide win over Alain Juppé in the second round of the centre-right Republican party primary, taking 67 per cent of the vote to Juppé's 33 per cent. 

What are his chances? With the left exhausted, divided and unpopular, it's highly likely that it will be Fillon who makes it into the second round of the contest (under the French system, unless one candidate secures more than half in the first round, the top two go to a run off). 

Le Pen is regarded as close-to-certain of winning the first round and is seen as highly likely to be defeated in the second. That the centre-right candidate looks - at least based on the polls - to be the most likely to make it into the top two alongside her puts Fillon in poll position if the polls are right.

As I explained in my profile of him, his path to victory relies on the French Left being willing to hold its nose and vote for Thatcherism - or, at least, as close as France gets to Thatcherism - in order to defeat fascism. It may be that the distinctly Anglo-Saxon whiff of his politics - "Thatcherite Victor vows sharp shock for France" is the Times splash - exerts too strong a smell for the left to ignore.

The triumph of Brexit in the United Kingdom and Donald Trump in the United States have the left and the centre nervous. The far right is sharing best practice and campaign technique across borders, boosting its chances. 

Of all forms of mistake, prophecy is the most avoidable, so I won't make one. However, there are a few factors that may lie in the way of Le Pen going the way of Trump and Brexit. Hostility towards the European project and white  racial reaction are both deeply woven into the culture and politics of the United Kingdom and the United States respectively. The similarities between Vote Leave and Trump are overstated, but both were fighting on home turf with the wind very much at their backs. 

While there's a wider discussion to be had about the French state's aggressive policy of secularism and diversity blindness and its culpability for the rise of Le Pen, as far as the coming contest is concerned, the unity of the centre against the extremes is just as much a part of French political culture as Euroscepticism is here in Britain. So it would be a far bigger scale of upheaval if Le Pen were to win, though it is still possible.

There is one other factor that Fillon may be able to rely on. He, like Le Pen, is very much a supporter of granting Vladimir Putin more breathing space and attempting to reset Russia's relationship with the West. He may face considerably less disruption from that quarter than the Democrats did in the United States. Still, his campaign would be wise to ensure they have two-step verification enabled.

A WING AND A PRAYER

Eleanor Mills bagged the first interview with the new PM in the Sunday Times, and it's widely reported in today's papers. Among the headlines: the challenge of navigating  Brexit keeps Theresa May "awake at night", but her Anglican faith helps her through. She also lifted the lid on Philip May's value round the home. Apparently he's great at accessorising. 

THE NEVERENDING STORY

John Kerr, Britain's most experienced European diplomat and crossbench peer, has said there is a "less than 50 per cent" chance that Britain will negotiate a new relationship with the EU in two years and that a transitional deal will have to be struck first, resulting in a "decade of uncertainty". The Guardian's Patrick Wintour has the story

TROUBLED WATERS OVER OIL

A cross-party coalition of MPs, including Caroline Lucas and David Lammy, are at war with their own pension fund: which is refusing to disclose if its investments include fossil fuels. Madison Marriage has the story in the FT

TRUMPED UP CHARGES?

The Ethics Council to George W Bush and Barack Obama say the Electoral College should refuse to make Donald Trump President, unless he sells his foreign businesses and puts his American ones in a genuine blind trust. Trump has said he plans for his children to run his businesses while he is in the Oval Office and has been involved in a series of stories of him discussing his overseas businesses with foreign politicians. The New York Times has detailed the extentof Trump's overseas interests. 

TODAY'S MORNING CALL...

...is brought to you by the City of London. Their policy and resources chairman Mark Boleat writes on Brexit and the City here.

CASTROFF

Fidel Castro died this weekend. If you're looking for a book on the region and its politics, I enjoyed Alex von Tunzelmann's Red Heat, which you can buy on Amazon or Hive.

BALLS OUT

Ed Balls was eliminated from Strictly Come Dancing last night, after finishing in the bottom two and being eliminated by the judges' vote.  Judge Rinder, the daytime TV star, progressed to the next round at his expense. 

AND NOW FOR SOMETHING COMPLETELY DIFFERENT

Helen reviews Glenda Jackson's King Lear.

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