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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Why did the Tunisian National Dialogue Quartet win this year's Nobel Peace Prize?

Thanks to Tunisia, it is no longer possible to argue that the Middle East and North Africa are inherently undemocratic or prone to violence.

It is a fitting that in a tumultuous year for global peacemaking, the Nobel Peace Prize has been awarded to the little-known Tunisian National Dialogue Quartet, a coalition made up of the union federation UGTT, the employers’ institute, the Tunisian human rights league and the order of lawyers . Over the past few years, the Quartet has been quietly shepherded in democracy to the country that lit the fuse of the Arab Spring. In part thanks to the efforts of this broad cross-section of civil society, Tunisia has stayed the course in transitioning from an authoritarian past to a democratic future, even in the face of terrorist violence and as other revolutions in the region have faltered.

The award comes at a time of escalating sectarian conflicts in Syria, Libya and Yemen. Islamic State’s campaign of terror has uprooted Iraqis and Syrians alike, driving desperate refugees into small boats to battle the waves of the Mediterranean. They join others fleeing to Europe from political and economic crises in Africa and Asia, forming a stream of humanity symbolising failures in leadership in three continents.

Among all this, it is not hard to identify why the Norwegian Nobel Committee awarded the world’s most coveted peace prize to the Tunisian Quartet.

First,Tunisia deserves to be celebrated for its momentous achievements in consolidating democracy. Unlike other countries in the region, it has trodden a path that is slow but solid, adopting a comprehensive and consensus-building approach to decision-making.

In this it provides a rare and extremely important example, not only for the region but also for the world. Thanks to Tunisia, it is no longer possible to argue that the Middle East and North Africa are inherently undemocratic or prone to violence.

Civil society steps up

Second, the role of civil society is fundamental for bringing about sustainable peace. Political leadership is important, but the scale of the challenge in transitional societies means that we cannot simply leave things to political leaders to sort out.

At local level especially, peace feels a lot more real when it comes with tangible improvements to quality of life. Citizens want to see the economy motoring again and to have confidence in the state’s institutions. They want to know that they can sleep soundly and safely, without fear of violence, persecution or poverty. Governments often lack the capacity and credibility to deliver these dividends alone. Civil society must step up to the plate – particularly the associations of trade, justice and human rights of which the Quartet is formed.

And third, the Quartet’s work relies heavily on forming constructive relationships across the political spectrum – from secularists to fundamentalists. It has walked a fine line, keeping disparate groups with diverging interests invested in an inclusive national process of dialogue. It has, in the words of the Norwegian Nobel Committee, laid the “groundwork for a national fraternity”.

Politicians are often the most cynical of creatures, yet the Quartet has managed to build a sense of collective endeavour among them. It has encouraged them to put the country’s best interest ahead of personal or sectarian interests, making this the guiding principle for decision-making.

Other bright spots

The transition in Tunisia is a work in progress and there will be more setbacks and successes. The country was left reeling from two terrorist attacks earlier this year, when 22 people were killed at the Bardo Museum in Tunis, and another 39 people died during an attack on a tourist resort in Sousse. But the message today is clear – Tunisia has made remarkable progress since 2010, despite the odds. This is in large part due to a credible and engaged civil society, a remarkable achievement in a new democracy. The country has forged a path of inclusive national dialogue from which many lessons can be learned.

Elsewhere this year, Myanmar goes to the polls in November – the country’s first free national ballot since 1990. Colombia is closer to lasting peace than ever, ending half a century of war that has taken 220,00 lives and uprooted six million people.

The US restored diplomatic relationships with Cuba, and also struck a landmark agreement with Iran over its nuclear programmes. And the UN has adopted the sustainable development goals, explicitly recognising peaceful and inclusive societies as a development priority for the first time. Behind every step forward there is an individual or institution worthy of the Nobel Peace Prize, but only one can win and the Tunisian National Dialogue Quartet is a worthy laureate.

Laura Payne is a Research Fellow and Director of RISING Global Peace Forum, Coventry University

This article was originally published on The Conversation. Read the original article.


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