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.)
The former rebel Syrian town of Douma on the outskirts of Damascus is seen on April 17, 2018. CRedit: Getty
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Trump’s “mission accomplished” boasts confirm the West has no serious strategy for Syria

The West has still not reckoned with its first mistake in Syria: demanding the removal of Assad.

On 4 April, three days before the latest chemical weapons attack in eastern Ghouta, the presidents of Iran, Turkey and Russia convened in Ankara for a tripartite summit to discuss the future of Syria. The meeting took place a year to the day after Bashar al-Assad’s Syrian regime dropped sarin on the town of Khan Sheikhoun in Idlib province, killing an estimated 74 people, but failed to incur any significant cost.

Nato member Turkey had once been the odd one out in this triumvirate and Recep Erdogan still has poor relations with Assad. But all three presidents now see their interests aligning as the hopeless UN-sponsored peace process stutters to a halt in Geneva. They are increasingly alienated from the West, have a substantive military presence on the ground within Syria, want to keep the Saudis and Israelis out, and regard themselves as the true power-brokers in the future settlement of the country.

The limited airstrikes against chemical weapons facilities on 13 April – conducted by the US, Britain and France – will not change that calculus. Iranian and Russian flags were prominent in a pro-regime celebration in Umayyad Square in Damascus that followed the next morning. President Assad’s office tweeted a short video of the Syrian leader nonchalantly strolling to work with his briefcase in hand. He was also pictured smiling warmly as he received a delegation of Russian parliamentarians. Russia continues to obstruct the UN-supported investigation by the Organisation for the Prohibition of Chemical Weapons, confident in the knowledge that useful idiots in the West will dance to its tune.

Once President Trump had publicly committed the US to reprisals against the Syrian regime, a menu of options was discussed by his administration and its allies. Reports from Washington DC suggest that cooler heads in the Pentagon prevailed against the hyper-hawkish impulses of the new national security adviser, John Bolton, who favoured a more spectacular attack on the regime to underscore US military prowess. James Mattis, the more cautious defence secretary, outlined the potential fallout should the US and its allies endanger the large Russian presence in the country. As Mattis put it, “right now this is a one-time shot”.

If anything, Assad and his sponsors will arguably be more concerned by a surprise attack on a military base near Homs that took place two days before the joint Western action. This is presumed to have been conducted by the Israeli air force, targeting a facility known as T-4, where there is known to be an Iranian presence. The same facility was hit by the Israelis in February and as far back as November 2013, Israel also entered Syrian airspace to strike a weapons storage facility that was being used by another of its mortal enemies, Hezbollah. Setting aside the question of Western involvement, much dry tinder remains in these overlapping proxy wars.

Meanwhile, as the House of Commons held its latest set-piece debate on the rights and wrongs of intervention in Syria, a familiar cast of characters played out roles for which they have often rehearsed. The truth is that Western handwringing has become ever more inconsequential since 2013, with a growing disconnect between the sense of moral urgency and any real leverage to influence events on the ground.

The first of the major Western missteps was the rush to declare that “Assad must go” at the very onset of the conflict in 2011. This was based on the conviction – an entirely reasonable one it would prove – that the Syrian regime was the chief aggressor in the civil war. The problem was that it was an aspiration dressed up as a policy. Once the rise of Islamic State gave perfectly ghoulish form to the fears about what might come in Assad’s place, the climbdown was clumsily managed. It not only cheapened the language of Western diplomacy, but diluted the element of deterrence supposed to give it weight.

A more prudent strategy, with a potentially better humanitarian outcome, would have been to avoid the rush to unachievable absolutes. By keeping open a range of diplomatic options, there would have been more latitude to exercise a tourniquet approach against the regime, setting its actions within bounds that could realistically be policed. Opportunities came and went to take measures stopping short of any substantive military intervention, such as the establishment of a no-fly zone to provide some space for talks to occur.

In the collective response of the US, UK and France to the latest attack, it has at least been established that Western tolerance for the proliferation and normalisation of chemical weapons still has some bounds, with the immediate risk of a major escalation with Russia and Iran also avoided. Yet Trump’s crass boasts of “mission accomplished” – repeated twice in recent weeks with reference to the campaign against IS and the attack on the Syrian regime – confirm that we cannot expect any serious diplomatic initiative or strategy to follow.

Equally, some of those who set themselves up as Trump’s greatest critics replicate the same selective hearing and self-satisfied preening. In his new book, A Foreign Policy for the Left, the veteran American leftist Michael Walzer exposes the “substitutes for thought” and “automatic positions” by which “reflexive anti-imperialist politics” has turned some on the left into apologists for abhorrent groups and regimes. No matter what the circumstances, the current Labour leadership unfurls the same tattered script every time. These absolutist anti-interventionists – who view Western involvement as the greatest evil and imbibe any fable that fits their worldview – have a serious case to answer too. 

John Bew is Professor of History and Foreign Policy at King’s College London and is leading a project looking at Britain’s place in the world for Policy Exchange. He is a New Statesman contributing writer and the author of Citizen Clem, an Orwell Prize-winning biography of Clement Attlee. 

This article first appeared in the 18 April 2018 issue of the New Statesman, Enoch Powell’s revenge