Less than half of dying patients are placed on a nationally recommended care pathway

(Press-News.org) Less than half of terminally ill patients are placed on the Liverpool Care Pathway for the Dying Patient (LCP) despite it being recommended nationally, concludes UK research published online in the BMJ Supportive & Palliative Care journal.

Durham University researchers found that in many parts of England, staff may have limited training or support to use the care pathway, which is a model of care 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 as a paper-based tool to help healthcare staff when caring for patients dying of cancer in hospitals, but it has been expanded to include all dying patients and has been implemented across the world in primary and secondary care settings.

It provides a framework for structuring and coordinating multidisciplinary care for the last 72 hours of life and facilitates audit by standardising the monitoring of patient needs, symptoms and care.

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

It has been seen by some as controversial 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.

Little 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, set out to review the evidence of the eligibility, uptake and non-uptake of the LCP in various settings.

They reviewed studies published between January 1990 and July 2012 that provided information on LCP uptake and found 17 suitable papers.

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, of whom 81% had a cancer diagnosis.

However, of the 236 patients judged to be eligible, around a third of them (79) died without the LCP in place.

They 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."

### [Assessing the uptake of the Liverpool Care Pathway for dying patients: a systematic review. Online First doi 10.1136/bmjspcare-2012-000406]