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Half of dying patients miss out on palliative care pathway

Liverpool Care Pathway not accessed by 52% of patients

Adrian O'Dowd

Tuesday, 04 June 2013

Around half of terminally ill patients are not placed on the Liverpool Care Pathway for the Dying Patient (LCP) despite it being recommended nationally, according to a study published online today in the BMJ Supportive & Palliative Care journal.

UK researchers found that in many parts of England, staff may have limited training or support to use the care pathway – a paper-based tool that enables healthcare professionals to focus on care in the last hours or days of life when a death is expected.

The pathway was jointly developed by the Marie Curie Hospice Liverpool and the Royal Liverpool University Hospitals in 2003 to help healthcare staff when caring for patients dying of cancer in hospitals, but has been expanded to include all dying patients.

In the UK, the LCP is cited in NICE guidance as an example of good practice and the Department of Health End of Life Care Strategy encourages commissioners and providers to ensure the availability of an end-of-life care pathway in acute hospitals, citing the LCP in particular.

However, the LCP has prompted controversy and last year, stories in the national media described it as the “equivalent of euthanasia for the elderly” that many doctors considered worthless. These articles led to hundreds of complaints to the Press Complaints Commission.

Not much is known about how much the LCP is used across the country so researchers from Durham University’s Wolfson Research Institute for Health and Wellbeing, in Stockton-on-Tees, reviewed the evidence of the eligibility, uptake and non-uptake of the LCP in various settings.

They reviewed 17 studies published between 1990 and 2012 that provided information on LCP uptake.

Collectively, 18,052 patients were placed on the LCP, in a variety of inpatient and primary care settings, and cancer and non-cancer diagnoses.

Rachel Stocker, who led the research, found that although the LCP is widely recommended, it was only used for 47.4% of dying patients, but the studies did not make it clear what proportion of patients were eligible for the LCP.
 
The researchers said possible reasons for this could be a lack of knowledge, high staff turnover, and concerns about applicability, particularly for unpredictable dying trajectories.

Only one study provided complete data to assess the proportion of all dying patients eligible for the LCP. It showed that 58% (236 patients of 407) were eligible for the LCP. However, of these 236 patients, around a third of them died without the LCP in place.

The researchers concluded: “The LCP is a well-known and well-regarded palliative care tool and this study confirms that it is used in a variety of geographical and clinical settings.

“However, this study provides evidence that around half of all dying patients were not placed on the LCP despite its availability. This raises questions about clinicians’ levels of knowledge and awareness about the LCP, and the appropriateness and applicability of this pathway.

“It is possible that clinicians are unconfident or unaware of the utility of the LCP, but equally possible that they deem the LCP to be inappropriate for patients for unknown reasons.”

DOI:10.1136/bmjspcare-2012-000406

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