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A pathway to care for the dying

It is worth remembering why the Liverpool Care Pathway (LCP) was invented.

It was not to hasten the death of patients, or to free up beds.The protocol for managing the final hours of patients who are dying was necessary because poor care and suffering were too common for patients who died in hospital. Indeed, Marie Curie Cancer Care, the charity that helped devise LCP, would say poor care was the norm.

Other doctors have described the LCP as invaluable, beneficial and humane. However, it has become controversial as a result of gross mistakes at a clinical and management level in the English NHS and, to some extent, in Scotland too.

Problems have all been with administration of the guidance within the LCP rather than the pathway itself. The protocol was never intended to cause death but to ease the passing of those already dying.

It enabled the planning in advance of care, discussion with family members and the avoidance of unnecessary treatment when it would cause more suffering.

But it was not used as intended. In England it became linked with misguided targets and discussion with patients and close relatives was often inadequate or simply absent.

Instead of the involvement of senior staff, decisions were taken by junior doctors. An independent review asserted that the LCP had been used as an excuse for poor quality care. It has become indefensible and tarnished.

Used correctly, it should have provided the personalised and sensitive approach being called for by the likes of Baroness Neuberger, who has carried out a review of LCP for the English NHS.

Already abolished in England, Health Secretary Alex Neil has confirmed the LCP will be abolished in Scotland too.

That is, on balance, the correct decision. But the lack of an immediate replacement is concerning.

The Scottish Government proposes setting up a new group to develop an alternative. In the meantime, "strong" guidance will ensure the maintenance of high clinical standards.

The Living and Dying Well National Advisory Group has produced that guidance. The group has led consideration of what should replace the LCP in Scotland, and believes the pathway has mostly supported good quality care but, in some cases, has inhibited it.

Generally, patients and their families understand that good palliative care can involve tough decisions. But they are wary of decisions to remove feeding or hydration even when someone is terminally ill. The advisory group recognises this. "Care must take into account the uncertainty involved in identifying if someone is dying," it states.

The process of creating a new, more transparent system should not be rushed. Neither should it take too long.

However good the interim guidance is, the longer staff are left in limbo or uncertainty, the more likely it is that poor practice will flourish. This is the opposite of what doctors, politicians and patients would want or intend.

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