Controversy fuelling emotion
It may seem like a while ago, and it is very likely that this is a topic that has fallen from the general public’s mind but I think that the story of the Liverpool Care Pathway (LCP) is a great example of how our healthcare system is bullied by politics and sensationalist coverage from the media.
The LCP was introduced in the 90s by a group of palliative care specialists at the Royal Liverpool University Hospital. The aim was to address a shortcoming in quality of care for the dying patient, initially rolled out to cancer patients it’s value was seen to extend beyond this patient group and it was eventually adopted nationwide.
Between the years 2009-2012 it attracted some pretty damaging news headlines and eventually the department of health announced that it would be phased out of use.
Essentially this boils down to whether or not you think that health professionals care about the dying or not. From my memory this seemed to start when it was felt that the pathway starved patients to death or killed them by withholding fluids. The news cycle snowballed from there, eventually claiming the the NHS was being paid to kill people.
To tackle the fluid debate, when a patient is in the dying phase they frequently stop eating and drinking. This is a part of the natural process of dying. What was claimed was that the pathway stopped patients from being artificially rehydrated with IV lines and fluids.
This is not entirely true, it is generally accepted amongst healthcare professionals (and this is unchanged since the discontinuation of the pathway) that when a patient is dying they should have as few painful procedures as possible. This would include the insertion of IV lines and taking of bloods. This naturally means that a patient will not be receiving artificial rehydration. It does not however, stop a patient from drinking orally should they wish to do so, but as we have already covered they are unlikely to want to during the dying phase.
An alternative which is rarely used and arguably of little to no benefit is subcutaneous fluid administration. This is done by a small needle being placed under the skin, seen to be less painful than having to gain IV access with a larger cannula, which is usually difficult in a dying patient and requiring multiple attempts, and fluid being allowed to pool under the skin. The body will absorb small amounts of fluid from this method. However, this has increased risk of infection and breakdown of skin causing ulcers – not particularly comfortable in itself.
Does this mean that all patients who are dying should not have IV fluids? NO – and crucially the pathway did not state that. Was it being used inappropriately by some healthcare professionals? Probably, they aren’t all amazing people after all and no matter what is out there some will always be better than others.
Well largely, what has changed? The answer is nothing. We still use the same medications, because they help patients with their pain and anxiety and breathing difficulties. we still don’t monitor the dying patient because it is invasive and uncomfortable and most of the time they do not want it. We still largely don’t give IV fluids, because the placing of frequent needles (in the dying this is quite frequently twice a day, and multiple attempts with disintegrating veins,) is deemed to be of more harm than good. And largely I think relatives of the dying agree. Are there still bad doctors out there that don’t manage the dying well? YES!
So in conclusion, was the Liverpool Care pathway a force for good or evil? I truly believe it was a guideline set out in good intentions which helped doctors to understand the dying phase, and manage it appropriately with medications that are not generally familiar to them in day to day practice.
What do you think?