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.)
Ellie Foreman-Peck
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Martin Schulz: could this man bring an end to the reign of Angela Merkel?

The German Eurocrat is the biggest threat to the possibility of a fourth term for Merkel. 

At first sight, Martin Schulz looks like an unlikely political saviour. Thin of hair and thick of waist, the 61-year-old was a member of the European Parliament for 23 years and its president for five. In an anti-establishment age, it was predicted that Schulz would struggle when he became the Social Democratic Party’s (SPD) candidate to replace Angela Merkel as the German chancellor in January. Instead, he is spearheading a remarkable revival in his tribe’s fortunes. On 19 February, for the first time in a decade, the SPD polled above Merkel’s Christian Democrats (CDU), attracting 33 per cent to their 32 per cent. The SPD vote share has increased by 12 points in a month. The cause is clear: “Martin mania”.

For months, it was assumed that Merkel would secure a fourth term as chancellor in September’s federal election. The SPD, the grandfather of European social democracy and Germany’s oldest party (it was founded in 1863), had polled as low as 19 per cent. After forming a grand coalition with the CDU in 2013, Schulz’s party was marginalised as Merkel claimed credit for policies such as the country’s first minimum wage. Voters defected to the far-left Die Linke and the far-right Alternative für Deutschland. The SPD’s future looked to be one of managed decline.

Sigmar Gabriel, the party’s leader since 2009, stood little chance of supplanting Merkel as chancellor. As a result, like François Hollande, he reached for the pearl-handled revolver: he announced his intention to step aside on 24 January after internal SPD polling showed that Schulz would perform significantly better against Merkel. “It was not an easy decision but I’m convinced it was the right decision,” Gabriel told reporters. His judgement was vindicated as public polls gave Schulz an 11-point lead over Merkel (49-38).

The German chancellor’s apparent unassailability owed less to her strength than to her opponents’ weakness. Eleven years after she entered office, voters had grown weary of Merkel’s leadership but saw no viable alternative. In Schulz, they have found one. Having been engaged at EU level and held no domestic office since standing down after 11 years as mayor of the north-western market town Würselen in 1998, Schulz has been embraced by voters as a relative outsider.

Unlike his SPD colleagues, Schulz can criticise the CDU’s record without appearing hypocritical or feeble. He has attracted voters with a centre-left emphasis on redistribution and social justice. “When people see that their taxes are used to give their children a future, they buy into it,” Schulz has said in interviews.

The European Parliament has been a useful platform for his pugnacious style. He is best known for being compared to a concentration camp guard by Silvio Berlusconi in 2003 and for his interjection in 2010 after Nigel Farage branded the then EU president, Herman Van Rompuy, a “damp rag”. Schulz retorted: “It’s not right that this man should be able to trample over the dignity of this house!”

Voters have warmed to Schulz’s personal story as well as his political history. He was born on 20 December 1955 in the village of Hehlrath, North-Rhine Westphalia, to a policeman father and a homemaker mother (he is the youngest of five). Rather than going to university, he trained as a bookseller and was a promising footballer. Two severe knee injuries ended his playing career at the age of 18 and he sought refuge in alcohol after falling into depression. Having contemplated suicide, he recovered to open a bookshop in his home town (which he ran until he became an MEP in 1994) and has been teetotal since 1980.

Schulz educated himself by devouring historical fiction (his favourite writers are John Steinbeck and Giuseppe Tomasi di Lampedusa) and retains the restlessness of an autodidact (he often works 18-hour days). His bonhomie and blunt manner appeal to voters who regard Merkel as aloof.

That Schulz has come to the SPD’s rescue is unsurprising. He joined the party at the age of 19 and became the youngest mayor in North-Rhine Westphalia when he was elected in Würselen at 31. After more than two decades serving the EU, the attractions of a return to domestic politics were obvious. “People must look into your eyes and see that you are a bloody streetfighter,” he remarked in 2013, as he presciently dismissed Ed Miliband’s electoral chances.

Schulz has disoriented the Christian Democrats, who failed to anticipate a centre-left renaissance. In a mark of how much he has unsettled them, the German finance minister, Wolfgang Schäuble, has denounced him as a Trump-like populist for his slogan “Make Europe great again”. Were Schulz to replace Merkel and Emmanuel Macron to be elected French president, the pair would unite in seeking to impose punitive Brexit terms on the UK.

For Germany’s Social Democrats, the fear is that Schulz’s surge has come too soon – voters could swing back to Merkel and the CDU before polling day. But after years as an emblem of centre-left malaise, the SPD has momentum. Schulz is determined to prove that there are second acts in political lives. 

George Eaton is political editor of the New Statesman.

This article first appeared in the 24 February 2017 issue of the New Statesman, The world after Brexit