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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Bernie Sanders is America’s most popular politician – and he’s coming after Donald Trump

Sanders, unlike Clinton, had a clear and coherent vision. As of now, he is the best hope the Democrats have of retaking the White House in 2020.

“I like Bernie Sanders,” my four-year-old niece in Texas said to me last month. “Why isn’t he president?” More than six months on from the defeat of Hillary Clinton, it’s a question that countless frustrated progressives across the United States continue to ask aloud.

Remember that the election of Donald Trump was not the only political earthquake to shake the US establishment last year. A 74-year-old, self-declared socialist and independent senator from the tiny state of Vermont, in a crumpled suit and with a shock of Einsteinian white hair, came close to vanquishing the Clinton machine and winning the Democratic presidential nomination. Sanders began the campaign as the rank outsider, mocked by the former Obama strategist David Axelrod as the candidate with whom Democratic voters might “flirt” and have a “fling” before settling down with Clinton. By the end of the campaign he had won 13 million votes and 23 states, and raised more than $200m.

In this dystopian age of Trump, it is remarkable that Sanders is now by far the most popular politician in the US – and this in a country where “socialist” has long been a dirty word. Increasing numbers of Americans seem nevertheless to “feel the Bern”. As such, Sanders supporters cannot help but ask the big counterfactual question of our time: would Trump be the president today if he had faced Bernie rather than Hillary in the election? Throughout the campaign, polls showed him crushing Trump in a head-to-head match-up. In a poll on the eve of the election, Sanders trumped Trump by 12 percentage points.

Democratic voters were told repeatedly that Clinton was more “electable” – but had they opted for Sanders as their candidate, there would have been none of the backlash over her emails, Benghazi, Bill, her Iraq War vote, or her Goldman Sachs speeches. So did the Democrats, in effect, gift the presidency to the Republican Party by picking the divisive and establishment-friendly Clinton over Sanders the economic populist?

I can’t prove it but I suspect that Sanders would have beaten Trump – although, to be fair to the much-maligned Clinton, she, too, beat Trump by nearly three million votes. Also, one-on-one polls showing Sanders ahead of Trump in a hypothetical match-up fail to tell us how the independent senator’s support would have held up against a barrage of vicious Republican attack ads during a general election campaign.

Then there is the matter of race. Clinton, despite deep support in African-American and Latino communities, was unable to mobilise Barack Obama’s multiracial coalition. Sanders would have done even worse than she did among minority voters. Trump voters, meanwhile, were motivated less by economic anxiety (as plenty on the left, including Sanders, wrongly claim) than – according to most academic studies, opinion polls and the latest data from the American National Election Studies – by racial resentment and an anti-immigrant, anti-Muslim animus. Sanders, who at a recent rally in Boston defended Trump voters from accusations of bigotry and racism, would probably have struggled as much as Clinton did to respond to this “whitelash”.

Nevertheless, Sanders, unlike Clinton, had a clear and coherent vision and I would argue that, as of now, he is the best hope the Democrats have of retaking the White House in 2020. His support for greater Wall Street regulation, debt-free college tuition, universal health care and a higher minimum wage is not only morally correct and economically sound but also hugely popular with voters across the political spectrum.

The Democrats have a mountain to climb. They have to find a way to enthuse their diverse, demoralised base while winning back white voters who are concerned much more by issues of race and identity than by jobs or wages. A recent poll found that the party had lower approval ratings than both Trump and the Republicans as a whole.

Yet press reports suggest that at least 22 Democrats are thinking about running for president in 2020. This is madness. Few are serious contenders – thanks to the dominance of the Clinton machine in recent years, the party doesn’t have a deep bench. There is no new generation of rising stars.

The only two people who could plausibly prevent Sanders from winning the nomination next time round are the former vice-president Joe Biden and the Massachusetts senator Elizabeth Warren. The good news is that all three of these Democratic contenders are, to varying degrees, economic populists, willing to stand up passionately for “the little guy”. The bad news is that the Democratic base may fantasise about a young, dynamic Justin Trudeau or Emman­uel Macron of their own but, come the 2020 election, Sanders will be 79, Biden 77 and Warren 71. (Then again, they’ll be up against a sitting Republican president who will be 74, behaves as if he has dementia and refuses to release his medical records.)

Bizarrely, that election campaign has already begun. On 1 May, Trump released his first official campaign ad for re-election, 1,282 days before the next presidential vote. Biden visited New Hampshire last month to give a speech, while Warren is on a national tour to promote her new bestselling book, This Fight Is Our Fight.

Sanders, however – riding high in the polls, and with his vast database of contacts from the 2016 race as well as a clear, popular and long-standing critique of a US political and economic system “rigged” in favour of “the billionaire class” – is the man to beat. And rightly so. Sanders understands that the Democrats have to change, and change fast. “There are some people in the Democratic Party who want to maintain the status quo,” he said in March. “They would rather go down with the Titanic so long as they have first-class seats.”

Mehdi Hasan is a contributing writer for the New Statesman and the co-author of Ed: The Milibands and the Making of a Labour Leader. He was the New Statesman's senior editor (politics) from 2009-12.

This article first appeared in the 18 May 2017 issue of the New Statesman, Age of Lies

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