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 power struggle with the military

Reminding your subordinates that you are "their boss" doesn't go as far as listening to their problems, it may seem.

This is the sixth in a series looking at why Emmanuel Macron isn't the liberal hero he has been painted as. Each week, I examine an area of the new French president's politics that doesn't quite live up to the hype. Read the whole series.

It had started well between Macron and the army. He was the first president to chose a military vehicle to parade with troops on the Champs-Élysées at his inauguration, had made his first official visit a trip to Mali to meet French soldiers in the field, and had pulled a James Bond while visiting a submarine off the Brittany coast.

It’s all fun and games in submarines, until they ask you to pay to maintain the fleet.

“Macron wanted to appear as the head of armed forces, he was reaffirming the president’s link with the military after the François Hollande years, during which the defence minister Jean-Yves Le Drian had a lot of power,” Elie Tenenbaum, a defence research fellow at the French Institute for International Relations, told the New Statesman. The new president was originally viewed with distrust by the troops because he is a liberal, he says, but “surprised them positively” in his first weeks. Olivier de France, the research director at The French Institute for International and Strategic Affairs, agrees: “He sent good signals at first, gathering sympathy.” 

But the honeymoon ended in July, with what Tenenbaum describes as Macron’s first “real test” on defence: the announced cut of €850m from the army’s budget, despite Macron’s (very ambitious) campaign pledge to rise the defence budget to 2 per cent of the country’s GDP by 2025. A row ensued between the president and the French army’s chief of staff, general Pierre de Villiers, when the general complained publicly that the defence budget was “unbearable”. He told MPs: “I won’t let him [Macron] fuck me up like that!”

Macron replied in a speech he gave to military troops the day before Bastille Day, in which he called soldiers to honour their “sense of duty and discretion” and told them: “I have taken responsibilities. I am your boss.” After the general threatened to quit and wrote at length about “trust” in leadership, Macron added a few days later that “If something brings into conflict the army’s chief of staff and the president of the Republic, the chief of staff changes.” That, Tenenbaum says, was the real error: “On the content, he was cutting the budget, and on the form, he was straightening out a general in front of his troops”. This is the complete opposite of the military ethos, he says: “It showed a lack of tact.”

This brutal demonstration of power led to de Villiers’ resignation on 19 July – a first in modern French politics. (de Villiers had already protested over budget cuts and threatened to quit in 2014, but Hollande’s defence minister Jean-Yves Le Drian had backed down.)

Macron did his best to own up to his mistake, assuring the military that, although this year’s cuts were necessary to meet targets, the budget would be rised in 2018. “I want you to have the means to achieve your mission,” he said.

But the harm was done. “He should have introduced a long-term budget plan with a rise in the coming years right away,” says de France. “It was clumsy – of course he is the boss, everyone knows that. If he needs to say it, something is off.” The €850m will be taken out of the army’s “already suffering” equipment budget, says Tenenbaum. “There are pressures everywhere. Soldiers use equipment that is twice their age, they feel no one has their back." The 2 per cent GDP target Macron set himself during the campaign – a “precise” and “ambitious” one – would mean reaching a €50bn army budget by 2025, from this year’s €34m, he explains. “That’s €2bn added per year. It’s enormous.”

Read more: #5: On immigration, Macron's words draw borders

Macron has two choices ahead, De France explains: “Either France remains a big power and adapts its means to its ambitions” – which means honouring the 2 per cent by 2025 pledge – “or wants to be a medium power and adapts its ambitions to its means”, by reducing its army’s budget and, for instance, reinvesting more in European defence.

The military has good reason to doubt Macron will keep his promise: all recent presidents have set objectives that outlast their mandates, meaning the actual rise happens under someone else’s supervision. In short, the set goals aren’t always met. Hollande’s law on military programming planned a budget rise for the period 2018-19, which Macron has now inherited. “The question is whether Macron will give the army the means to maintain these ambitions, otherwise the forces’ capacities will crumble,” says Tenenbaum. “These €850m of cuts are a sign than he may not fulfill his commitments.”

If so, Macron’s row with the general may only be the beginning.  It didn’t help Macron’s popularity, which has been plummeting all summer. And the already distrustful troops may not forgive him: more than half of France’s forces of order may support Marine Le Pen’s Front national, according to one poll. “It’s hardly quantifiable and includes police officers,” Tenenbaum cautions. All the same, the army probably supports right-wing and hard-right politicians in higher numbers than the general population, he suggests.

James Bond would probably have known better than to irritate an entire army – but then again, Bond never was “their boss.”