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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Emmanuel Macron's French election victory may change less than most expect

The centrist is not the first to succeed from outside the traditional parties in the Fifth Republic.

Emmanuel Macron has won the first round of the French presidential election, and will face Marine Le Pen in the run-off.

The numbers that matter: Emmanuel Macron 24 per cent, Le Pen 21 per cent, François Fillon 19.9 per cent, Jean Luc Mélenchon 19.9 per cent and Benoît Hamon 6.3 per cent.

According to the polls - which came within 0.9 per cent of the correct result in the first round - Macron will easily defeat Marine Le Pen in the second round.

The single transferable take that compares Macron to Hillary Clinton and Le Pen to Trump ignores a few things. Not least his programme, the different electoral system and the fact that Macron is popular - the most popular politician in France, in fact. Jean Luc Mélenchon declined to back a candidate in the second round and will poll his supporters on who his leftist bloc should back. But it's not comparable to the feud between Bernie Sanders and Clinton - which, in any case, was overwritten. Most Sanders supporters backed Clinton in November. The big story of that election was that the American mainstream right backed Donald Trump despite his manifold faults.

The French mainstream right is a very different beast. Fillon has already thrown his weight behind Macron, warning against the "violence" and "intolerance" of the National Front and the "economic chaos" its programme would inflict. And to the extent that it matters, Hamon has also endorsed his former party colleague, saying that there is a difference between a "political adversary and an enemy of the Republic."

So, if he wins, has everything changed, changed utterly? That's the line in most of the papers this morning, but I'm not so sure. French politics has always been more fissiparous than elsewhere, with parties conjured up to facilitate runs for the Presidency, such as the Democratic Movement of perennial candidate, now Macron backer François Bayrou, and Mélenchon's own Left Party.

I'm dubious, too, about the idea that Macron is the first to succeed from outside the traditional centre-right and centre-left blocs in the history of the Fifth Republic. That honour surely goes to Valéry Giscard d'Estaing, a popular finance minister in a Gaullist administration, who ran on a independent centrist platform in 1974 - and won the presidency.

Giscard d'Estaing had no majority in the National Assembly and had to "cohabit" with his former colleagues on the Gaullist right. In the long run, far from upending the left-right pattern of French politics, he continued it. (Indeed, d'Estaing is now a member of the centre-right Republican Party.)

You don't have to look hard to see the parallels with Macron, a popular finance minister in a Socialist administration, running on an independent centrist platform and very likely to win, too.

France's underreported and under-polled legislative elections in June will give us an idea of the scale of the change and how lasting it may be. If, freed from the taint of Fillon's scandals, the French Republicans can win the legislative elections then talk of the "death of the traditional centre-right" is going to look very silly indeed.

Equally, while Hamon won the presidential nomination, the Socialist Party's legislative candidates are largely drawn from the party's right. If En Marche!, Macron's new party, can go from no seats at all to the largest group but are short of a majority their natural allies in getting through Macron's programme will be from the remains of the Socialists. Far from irrevocably changing the pattern of French politics, Macron's remarkable success may simply mark a period of transition in the life of the French Left.

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

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