Talk:Liverpool Care Pathway for the Dying Patient

Now discredited

Now withdrawn. Some people like claiming it's discredited rather than the politicians bowing to the media making end of life care harder. Neonchameleon (talk) 20:06, 20 March 2018 (UTC)

Interesting view that witholding water, one of the most fundamental requirements of a living organsism, is described as 'care'. — Preceding unsigned comment added by 86.167.143.65 (talk) 03:34, 2 February 2019 (UTC)

Biased Government Review - evidence of a cover up to avoid Corporate Manslaughter charges?

Lamb and Hunt have rejected calls for a public inquiry, preferring to order a review, peculiarly allowing those responsible for roll out of the LCP across the NHS to review themselves. . One of these organisations - who have already informed government policy, is the “Association for Palliative Medicine of Great Britain and Ireland” In several DoH press releases, they have variously described them as ‘representing’ or ‘having a membership of 1,000..’ or ‘..over 1,000..’ palliative care practitioners in the United Kingdom. This implies that they are highly knowledgeable in this field, and are best able to provide input to a government review of the pathway, which has been exported to over 22 countries bearing both the NHS and DoH logos. However, according to the registration documents filed at the Charity Commission, their membership is in no way confined to registered medical or nursing practitioners – “The APM exists to promote the advancement and development of palliative medicine and is recognised as representing physicians at all grades who work in palliative medicine and those with an interest in the specialty”. It is therefore open to almost anyone ‘interested’ in the specialty – I believe some could obtain full membership with an Aromatherapy or Homeopathy Diploma. More than half of its members pay a reduced subscription, indicating they are unqualified students (compare this charity's unaudited accounts (http://www.charity-commission.gov.uk/Accounts/Ends72%5C0001053572_ac_20111130_e_c.pdf) to membership fees at (http://www.apmonline.org/page.php?pageid=146) . Moreover, it has a worldwide membership, raising the possibility that some members have qualifications that would be insufficient to practice in the United Kingdom. There is nothing whatsoever to preclude its membership including people who had been struck off by the GMC or NMC for misconduct or bad practice. Many could just be ‘friends of the hospice’, necrophiles, or even medical practitioners responsible for harvesting organs from prisoners receiving the death penalty in Chinese prisons (where LCP drugs are used to avoid damaging healthy tissues). Jane Barton – who was found guilty of dangerous prescribing leading to the deaths of at least 12 vulnerable but non-terminally ill patients in the Gosport War Memorial Hospital over a decade ago, could be a member, and could thus be informing the DoH on ‘best practice’ in the care and support of some of our most vulnerable citizens.212.139.100.155 (talk) 10:59, 7 December 2012 (UTC)C.Probst212.139.100.155 (talk) 10:59, 7 December 2012 (UTC)

'Dying Matters' are also conducting an 'independent review' on behalf of Lamb and Hunt: however, on page 18 of their most recent accounts filed at the Charity Commission (http://www.charity-commission.gov.uk/Accounts/Ends71%5C0001005671_ac_20120331_e_c.pdf), they receive an income from both Marie Curie (the LCP originators) and MacMillan Cancer Support . AND received £650,000 from the Department of Health and the National End of Life Intelligence Network!!!! They also receive money from Pfizer and several other pharmaceutical companies (see p 20) , and Andrew Lansley and Joan Bakewell were guest speakers at one of their lavish 'doos'....how on earth is this an 'independent review'???

Criticism

" This story was criticised by the Association for Palliative Medicine and the anti-euthanasia charity Care Not Killing as inaccurate.[4][23] " 23. ^ Liverpool Care Pathway, Care Not Killing, 15 September 2009. " The audit, which was conducted by the Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians and the results of which were made public yesterday, underlines the value of the LCP in providing a framework for decision-making by doctors treating imminently dying patients."

The problem is that this audit was carried out by the Mary Curie Palliative Care Institute, which invented the Liverpool Care Pathway. I think this is a clear conflict of interests. MrSativa (talk) 06:03, 13 June 2017 (UTC)

Saving Costs In A Time Of Austerity

What hasn't been mentioned is the cost saving aspect of the Liverpool Care Pathway. The LCP is in operation in different countries under different names. In the Netherlands it's called Zorgpad Stervensfase.

Goedkoper

Het project bleek ook kostenbesparend, zo bleek uit een steekproef. Er werden twee onderzoeksgroepen opgesteld: een met patiënten behandeld door het palliatieve team en een met patiënten behandeld op de reguliere manier. De kosten van de patiënt behandeld door het palliatieve team bleken 40 euro per dag lager te liggen. Bovendien bracht het team geld op door de consulten. Douma: ‘Het is goedkoper omdat de patiënt minder onderzoeken en behandelingen krijgt door goede palliatieve zorg. Door dit soort kostenbesparingen wordt zo’n project ook interessant voor de Raad van Bestuur.’

Cheaper

The project also proved to be cost-effective, as was shown in a sample. Two research groups were drawn up: one with patients treated by the palliative team and one treated with patients in the regular way. The costs of the patient treated by the palliative team were found to be 40 euros a day lower. In addition, the team raised money through the consultations. Douma: "It's cheaper because the patient gets fewer tests and treatments because of good palliative care. This kind of cost savings also makes such a project interesting for the Board. "

MrSativa (talk) 06:38, 13 June 2017 (UTC)

References

Use of Letters to the Editor as a source

There is a dispute about this: see [1]. I looked at the Reliable Sources doctrine and the position there is unclear. It seems to me that letters should be considered to be like blogs and not used as sources. In the case of the letter from the physicians to the Telegraph, that is a somewhat different case, because there is an article in the Telegraph specifically about that letter, which makes it more noteworthy. I would like to hear what other people think about this, but if there continues to be a dispute I think the solution is to not use any letters to the editor as a source for this article. —Preceding unsigned comment added by Reef Bonanza (talk • contribs) 15:21, 13 January 2010 (UTC) sock of banned editor

When the article is discussing the controversy that arose, it is entirely appropriate to show the letters as primary documents in that public controversy. We're not citing the letters as the final word, we're showing reactions that were taken at the time (from people who, given their positions, might well anyway be considered reliable sources). It is also in itself a service to link the reader to the amplifying and clarifying statement by Dr Hargreaves, which adds usefully to the original article -- the view from the horse's mouth is often more reliable that that mediated by a journalist!

We mustn't have an agenda here: it is valuable to show the spread of opinion. Jheald (talk) 09:54, 17 January 2010 (UTC)

Why does everything have to be described as a controversy in wikipedialand?

Anyway, I would say that it's more likely a notability issue, rather than sourcing. Is there enough professional medical objection to the Liverpool Care Pathway to be significant? Essentially you've got five clinicians and one other, two of whom are representatives of overtly pro-life lobby organisations. Given the size of the palliative care industry in the UK is that really significant?

It's a four month old story, to demonstrate adequate notability of the position it should be corroborated by something else, preferably a professional medical source, probably from the ethics community. Otherwise I'm unconvinced that it's significant enough to be worth noting.

Are there any instances of Acute Trusts deciding not to adopt the LCP as an approach?

ALR (talk) 18:20, 21 January 2010 (UTC)

The story ran for about a week, and was picked up with developments and comment by all the UK main broadsheet newspapers. It also received quite wide play in the U.S., with some more Republican elements jumping on it (rather dubiously) as epitomising Sarah Palin's "death panels". So from that angle, I think it probably is notable.

I think it is also worth noting medically (though disclaimer: I am not a medic, and I am sensitive that this is a very sensitive area). But as I understand it, there is a divergence in default practice between the U.S. (where keeping somebody on a drip in most places probably is the default), and the U.K. (where at the very end it probably isn't).

My understanding is that the arguments are quite balanced:

• For somebody at the very end stage, whose organs are shutting down, including their kidneys, artificial hydration may do no more than cause excess water retention, with unnecessary unpleasantness and discomfort. In some cases, eg some terminal heart conditions, this may in itself be life-threatening.
• On the other hand, if there is dehydration, insufficient solvation of the breakdown products of morphine-based pain relief can cause avoidable delirium and tremors, which may in turn lead to heavier than necessary sedation.
• There is also possibly a suggestion that perhaps in parts of the hospice movement it may have become accepted folk-wisdom, that dehydration may be a "not bad" death; that if it is a little more ordered and a little less painfully drawn out for relatives, and if the patient is perhaps a little more calm and sedated facing their last final hours, that may not be the worst of all outcomes.

IMO, that together with the media flurry last year, and its international pick-up, meant that the issue was worth basically a passing nod in the article, not much more; which IMO I think the article got about right. I also think it's a subject that could and probably should deserve a more detailed treatment on WP, but not here -- we should, I think, probably have a full article on final-hours end-of-life care, and in my view that would be the proper place to examine this in appropriate detail.

Regarding Trusts decifing not to go with the LCP, it's worth noting that the LCP just establishes a standard default baseline going forward. It doesn't forbid deviation -- in fact clinicians are free to deviate from it at will according to their clinical judgment, so long as they note what they have done and why. So I think it shouldn't lead to a hospital abandoning the LCP, if the team had issues about this, just a recognition that the issue involved particular clinical considerations. Part of the whole point of the LCP is to establish a data-gathering framework which can identify systematic "deviations" from baseline of this kind, so that differential outcomes and best practice can be refined and investigated.

It's also worth noting that, I think I'm right in saying, even now only a fraction of the NHS currently has actively taken on implementing the LCP. Jheald (talk) 20:05, 21 January 2010 (UTC)

That's all essentially analysis, the point of my comments above is that by demonstrating notability you deal with the sourcing issue. From your description it sounds as if there is one letter, with some media commentary on that. I'll repeat the suggestion that an acceptable level of evidence would be informed discussion in the medical press. One letter, and some media interest in it, isn't significant enough to worry about.

The whole issue of death and how to deal with the patient and the family is an issue in medical ethics, there are several schools of thought.

I'd suggest stepping back from what you think and considering what the evidence says.

ALR (talk) 20:44, 21 January 2010 (UTC)

It's a talk page. Analysis is appropriate. But I was actually just about to start adding some references -- which, as I wrote above, are relevant to the issue, but in my view not appropriate to the article. Here are the first two:

A reference supporting cessation of artificial hydration:

• Robert Becker (9 December 2008), Providing hydration at the end of life: ethics and practice, Nursing Times, 9 December 2008

A reference expressing concern (in addition to the above cited letter by Dr Hargreaves):

• Gillian Craig (Apr-May 2008), Palliative care in overdrive: patients in danger, American Journal of Hospice & Palliative Care 25(2), 155-60. PMID 18445867

Jheald (talk) 20:50, 21 January 2010 (UTC)

I don't have access to the Craig paper,. although note that she's associated with one of the two lobby groups I mentioned with reference to the letter, so I'd question independence.

The second reference doesn't make reference to the LCP, it talks about hydration, which is only one part of the LCP. I'm afraid that implying that the paper is a criticism of the LCP would be synthesis.

Essentially we come back to the point about the references. If you can present references that explicitly discuss any controversy, as opposed to academic debate about the LCP then you have no issues, until that time mentioning the issue gives it undue weight.

Opposing views is an essential element of the scientific method, I think you'd be hard pressed to find anything in recently developed healthcare that isn't disputed by someone. It becomes notable when there is significant dispute. Clearly some areas have a fairly small dissenting community and yet it becomes notable anyway, climate change springs to mind, but this doesn't appear to be significant enough.

ALR (talk) 21:01, 21 January 2010 (UTC)

Note added:

TimVickers (talk · contribs) has now so much improved the article beyond recognition that the previous discussion here is essentially moot; but, just to clarify, I was citing Robert Becker as someone essentially agreeing with the LCP version 11's basic presumption against artificial hydration unless it's decided to be clinically indicated.

As well as the letter by Dr Hargreaves that kicked off this discussion ("The key issue is that there are numerous clinical situations which mimic the dying phase, including dehydration. The hospice movement in Britain continues to teach that rehydration via a drip is rarely necessary – despite evidence from America to the contrary – and that the use of a drip "medicalises dying"... Dehydration can cause the build-up of toxic metabolites from morphine and other drugs, resulting in confusion, drowsiness and jerking or twitching. This is then often managed by sedation rather than rehydration."), in reading for this article I was also struck by this letter to The Times (2 October, 2009) from another end-of-life specialist (Dehydration and perfect care at the end of life), especially its difference in tone compared to this letter from 22 September. The U.S. National Cancer Institute does note that "hydration and rotation to other opioids are the primary treatments" when opioids are implicated in the development of myoclonus [2]. However, Northwestern University emphasises some of the possible adverse effects [3], echoing Dr Becker's concerns. Finally, here's a 1995 article by Ira R. Byock MD on the issue, which may have had some influence. [4].

The 2009 audit found that one in ten patients on the LCP were recorded as receiving artificial hydration. Jheald (talk) 22:51, 28 January 2010 (UTC)

(Outdent) No, with respect, it's not undue weight. If you run a Google news search on the LCP, this is what comes back. If you want to know the context it has been mentioned in the United States, this is that context. If you want to know how it has been (mis?)characterised in the press, this is how it has been (mis)characterised.

That makes the issue worth a reference. Per WP:NPOV. Not worth undue coverage, but worth a mention. Jheald (talk) 21:16, 21 January 2010 (UTC)

I agree it is probably worth mentioning, but since the large majority of reliable sources do not take this view (to put it mildly) devoting much more of a sentence to this newspaper story would be giving it undue weight. I've tried to add a selection of the most recent research on the topic, but there is much more out there that could be cited in addition. The article is also not terribly clear on exactly what the pathway involves, this could be improved by somebody with a better grasp of the subject. Tim Vickers (talk) 22:09, 21 January 2010 (UTC)

The Pathway IS a one way street to death

RE: your comments in the 'Components' section: its an 'End of Life Care Pathway'. With patients heavily sedated on prn midazolam, as prescribed in the LCP for 'agitation' (which they all seem to have according to the subjective assessments of the doctors carrying out this plan!), and with all 'unecessary ' treatments withdrawn , noone could actually tell if there had been any improvement or not - what is the source of your estimate of 3% of patients recovering after being placed on the LCP? They used to find some people alive in the gas chambers at Auschwitz after every session, you know, those who adventitiously found an air pocket - could you give some examples of patients surviving the LCP and cite a reference? My source was 'Shoah' - an interview with a man named Mr. J. Vrb, who was forced to work in the crematoria or get thrown into an incinerator alive....he said one or two from every gassing session would still be found alive - thats about 3%, given the average size of the gas chambers.

Here's a reference to one patient who 'survived' the LCP - Mrs Fenton <http://www.timesonline.co.uk/tol/life_and_style/health/article6869646.ece> . Her daughter rescued her from the hospital - is she and those like her amongst the 3% who survive? Are they just the ones who have relatives to take them away? She had antibiotics withdrawn - your article says 'they are put on the LCP, and if there is no further deterioration, they pathway is withdrawn'. How odd! So if you manage to survive an infection without antibiotics, you live, if not, you're just left to die? The entire article lacks any form of valid analysis or logical argument.79.77.10.61 (talk) 03:50, 21 March 2010 (UTC)DrLofthouse79.77.10.61 (talk) 03:50, 21 March 2010 (UTC)

Excellent points. It is a self fulfilling prophecy, they are prepping patients and their relatives for them to die, and they don't do anything to extend their lives. What could go wrong? At least it saves them a lot of money in hospital stays, operations and recovery. Why is it so difficult to find an organisation to organize against this policy? MrSativa (talk) 06:16, 13 June 2017 (UTC)

Is the efficacy of any other treatment regime in the NHS assessed by the number of people who SURVIVE it, by the way? If any other treatment only had a 3% survival rate, do you think it would be recommended by NICE? —Preceding unsigned comment added by 79.77.10.61 (talk) 03:53, 21 March 2010 (UTC)

You might find this recent article in the Catholic Herald interesting. Tim Vickers (talk) 17:15, 5 May 2010 (UTC)

It appears to have been removed Tim.79.70.235.31 (talk) 20:46, 17 December 2012 (UTC)CProbst20:46, 17 December 2012 (UTC)

The Bexley problem

First recorded in the Memorial Hospital at an Oxleas NHS Foundation Trust Governors' Awayday, 20.1.2011, it was stated by one who had experienced using the pathway with older relatives that not all elders take well to the 'Liverpool' tag ('I don't want to go to Liverpool!').--86.31.105.33 (talk) 12:37, 23 January 2011 (UTC)

The Beckenham Question

Especially considering that the choice whether or not to accept resuscitation, if that, may be the only taste of the Liverpool Care Pathway which most people will ever get, the question arises as to whether a refusal of resuscitation implies a poor quality of life in the current patient(?).--86.31.105.33 (talk) 12:42, 23 January 2011 (UTC)

Murder or Manslaughter with no written consent of patient?

I feel that the criticism of the current attempts by several hundred families to have teh LCP withdrawn are being misrepresented here....the objections are to its abuse..ie the fact that it is being used without the express consent of patients. It also lacks any independent audit as to the accuracy of the decision that the patient is truly at the 'end of life', which it leaves to the individual clinical judgement of a doctor. It has been rolled out across the NHS, despite the LCP site itself describing it as a work in progress ...i.e. it was instituted without any effort at quality control, but was not 'mandated' by the DOH; this renders the NHS itself, along with the PCTs liable for 'corporate manslaughter' in potentially thousands of cases. 80.42.238.111 (talk) 03:18, 4 November 2012 (UTC)Dr Lofthouse80.42.238.111 (talk) 03:18, 4 November 2012 (UTC)

The centre at which the LCP was formulated admitted liability for the death of a patient who had been cured of cancer months before, but who merely returned to the unit for advice on a heavy cold (http://www.dailymail.co.uk/news/article-1219853/My-husband-beaten-cancer-doctors-wrongly-told-returned-let-die.html). In an obvious attempt to avoid negative publicity, the unit settled out of court shortly before the first audit of the care pathway was published.79.75.213.206 (talk) 23:22, 18 November 2012 (UTC)Dr Lofthouse79.75.213.206 (talk) 23:22, 18 November 2012 (UTC)

Hydration

What proportion of patients placed on the LCP also have their hydration or nutrition withdrawn? I note that such withdrawal is not written down as part of the LCP but I wonder if it is accepted practice in some places. Food and water are basic human rights and if the LCP is associated with a denial of human rights then this would deserve mention. You might not recover from whatever put you in hospital, but you surely have the human right not to be starved to death there. — Preceding unsigned comment added by 86.53.69.150 (talk) 22:54, 8 July 2012 (UTC)

The most extensive recent statistics on the LCP appear to be the National Care of the Dying Audit of Hospitals, 2011.

According to pages 81-82, for patients for whom full documentation was available:

• 84% of patients were not receiving artificial nutrition when put on to the LCP. Of the remaining 16%, 2% of the total continued on artificial nutrition ((ie most likely a nasal tube)) and 15% did not.
• 56% of patients were not receiving artificial hydration when put on the LCP. Of the remaining 44%, 16% of the total continued on artificial hydration ((ie most likely an i.v. drip)); 28% did not; and 0.4% began artificial hydration.

Other statistics which may be of interest:

• 89% had been having routine blood tests. This was discontinued in all but 1% of patients (page 43)
• 81% had been receiving intravenous antibiotics. This was discontinued in all but 4% of patients. (page 44)
• 79% had been having blood glucose monitoring. This was discontinued in all but 2% of patients. (page 44)
• 92% had been having their routine vital signs recorded. This was discontinued in all but 4% of patients. (page 45)
• 85% had been receiving Oxygen. This was continued in 40% of patients, discontinued in 45% of patients, and commenced in 0.4% of patients. (page 45)
• Of 242 patients with an Implantable cardioverter-defibrillator, this was deactivated in 77% of the cases. (page 47)

So: no more antibiotics; heart defibrillators switched off for three-quarters of patients with them; and Oxygen therapy discontinued for over half of those receiving it.

(More to come) Jheald (talk) 21:46, 9 July 2012 (UTC)

(Continued) Pretty bleak, isn't it ?

I should emphasise that I'm only a lay-person, and I'd prefer the article to be based on a balanced view of the medical literature from a position of knowledge, rather that what the Daily Mail thinks it can stir up as a moral panic, or my own hit-and-miss reading. So I've consciously left the article in the hope it might be addressed by editors who are more bio-medical specialist, with more background in the field, rather than jump in again myself.

But on my reading as a layperson, I do think it's important to realise that the LCP is intended for people in a very bad way indeed, for whom the medical team believe that death is now imminent, and that there is no possible intervention available that they believe is likely to stabilise the patient.

If you look at cancer charity websites, for example Marie Curie or Macmillan in the UK, or the National Cancer Institute in the United States, or other websites about end-of-life care, they appear to organise their advice into different timeframes -- last months, last weeks, last hours. The LCP is about the last hours. Almost 50% of patients die within 24 hours of being put on the LCP. (Cancer patient median 27 hours; non-cancer patient median 31 hours -- Audit, p. 85). That's not because of the LCP; it's because they were put on the LCP when their deaths appeared inevitable, and imminent.

Well, that's what the paperwork says.....relatives tell a very different picture.80.42.238.111 (talk) 03:18, 4 November 2012 (UTC)Dr Lofthouse80.42.238.111 (talk) 03:18, 4 November 2012 (UTC)

The goal of the LCP is not to shorten life -- which is why it has the support of anti-euthanasia groups like Care Not Killing, and of Catholic doctors, and of Jewish doctors ("preserve life"). In fact, if I remember correctly, published studies suggest people may live slightly longer on the LCP. But the goal is to make sure that as often as possible the process is managed in a systematic organised way, rather than an ad-hoc improvisation every time, so that things don't get missed; so that the whole medical and support team are involved; so that patients can be made as comfortable as possible; so that families are involved; so that interventions can be made as soon as needed, when needed, to control symptoms.

There are surely times when things could go better, particularly for families; but the levels of symptom control being reported on pages 51 to 56 of the Audit are surely pretty impressive, however distressing the percentage of cases where control is not achieved may be; as well as the drive throughout the documents and statistics on trying to emphasise and improve communication. Jheald (talk) 22:54, 9 July 2012 (UTC)

(Continued) As to the hydration and the nutrition, it is worth noting that if you have heart or lung or kidney problems then hydration may be what you absolutely do not want -- if you have heart or lung problems so that hydration would lead to water in the lungs, the hydration could directly make it painful and more difficult to breathe; while if your kidneys are packing up, there are issues about putting ever more water into the body when there's no way it's coming out, again just leading to potentially considerable discomfort. These are all quite common conditions at end of life.

It's also I think almost become received wisdom, particularly in the last ten years, that perhaps a degree of dehydration is not such a bad way to go. There are claims that it's something that the dying body hardly notices, or even that it leads to the release of endorphines that can help the patient in their last hours. It's not something I feel qualified to assess, but you can certainly find material and discussion on this if you google "end of life" + hydration.

Again, this also comes back to the different stages of end-of-life -- last months, last weeks, last days/hours. It is a very common, recognised signal as the body moves into the final end-phase, that there may simply be no appetite for any further food or drink, regardless of whether or not the patient is still able to swallow. It's not that people are being deliberately starved or parched -- as far as I am aware, the general rule is that if a patient wants something to ehat at or drink, then they should if at all possible be given it, even if there is a quite real risk of choking, with enforced nil-by-mouth absolutely the last option if it can be avoided. But rather the reality is that very many patients get to a point whether they simply no longer have any wish to eat or to drink. This can be something that is particularly hard on families, particularly if they have seen the patient succumb to anorexia-cachexia syndrome, like 80% of terminal cancer patients, and literally waste away. It's so easy to feel that if one could just persuade the patient to eat something, to absorb some nutrition, then they could start getting better. But when a time has come, when the medical team judges that death is soon and inevitable, and that no intervention they could make would stabilise the situation, then one has to ask whether force-feeding unless the patient requests it would really be appropriate.

I query the value of these figures as 'statistics', on the description of how the figures were collected - from the horses mouth (Marie Curie Palliative Care Institute Liverpool). There is a cash incentive for showing 'continuous improvement' in compliance with the LCP. Every participating centre had to submit data from only 30 patients - their nursing staff were able to choose which patient's anonymised data they submitted.

This constitutes a mere 0.04% of the patients who have died on this pathway. The figures used to support the LCP in the Care of the Dying Audits are, for this reason, one of the most risible uses of 'statistics' I have ever encountered. There is no evidence base whatsoever for 'palliative care' - none at all. The breaches of the Mental Capacity Act 2005 alone demonstrate why it should have been suspended years earlier. 212.139.102.76 (talk) 01:41, 11 February 2013 (UTC)DrLofthouse212.139.102.76 (talk) 01:41, 11 February 2013 (UTC)

Some possibly useful links:

• Oral feeding difficulties and dilemmas, Royal College of Physicians and British Society of Gastroenterology, January 2010
  • Subtitled "A guide to practical care, particularly at the end of life", and contains extensive background and overview material. The launch press release emphasised that "nil by mouth should be a last resort, not a first option"; but note also eg section 1.90 on page 18: "good mouth care rather than attempting to feed the patient becomes the more appropriate intervention".
• Artificial Nutrition & Hydration: Guidance in End of Life Care for Adults. National Council for Palliative Care
• Last Hours of Living, Northwestern University, End-of-life care education, module 12
• Treatment and care towards the end of life: good practice in decision making, General Medical Council, July 2010

• See especially page 52 and following, especially section 113 and following; also note on page 75.

• Subcutaneous fluids in Palliative Care, NHS Scotland, August 2010
  • Current Scottish guidance on hydration. "In the last days of life, artificial fluids and feeding that have been started previously should be reviewed, and usually discontinued".
• LCP Helpful References - Bibliography of papers, maintained by the LCP central organisation itself

Jheald (talk) 01:19, 10 July 2012 (UTC)

Here is also a blog entry (so not admissible as a Reliable Source here) from a medical Specialist Registrar with expertise in Elderly Medicine, who is now living herself with a diagnosis of terminal cancer. While there's certainly plenty of fear and uncertainty about the LCP, and for some a very real sense of hurt and betrayal, which some parts of the media have done their level best to build up -- and which, to be fair, is a very real story, which we are right to cover here -- in my view this blog entry (and also some of the comments attached) gives a good sense of perspective. Jheald (talk) 16:03, 5 November 2012 (UTC)

@ JHeald: could you tell me which 'terminal illness' Rusty Lee's mother was 'diagnosed' as suffering with before her daughters insisted she was taken off the LCP and placed on antibiotics for her lung infection? 79.75.213.206 (talk) 23:26, 18 November 2012 (UTC)Dr Lofthouse79.75.213.206 (talk) 23:26, 18 November 2012 (UTC)

Opinion?

From the article... "Since the LCP has come into existence, 130,000 people have been put to death under this NHS protocol." — Preceding unsigned comment added by 193.61.118.250 (talk) 16:29, 9 July 2012 (UTC) ou

Good catch. It should of course be 130,000 per year.

In my view the entire recently-added "Controversy" section is deeply problematic and needs wholescale re-writing. The use of phrases like "put to death" is symptomatic of problems through and through the whole section. I was just hoping that somebody else would step up to the plate... Jheald (talk) 02:49, 10 July 2012 (UTC)

In this series of edits I have rewritten the latter part of the "Controversy" section. The opening paragraph is also in need of attention but I'm going out now. This recent publicity is part of a notable controversy which needs to be addressed in this article (though it may belong in the "Reception" section), but in neutral, encyclopedia style, and content needs to conform to Wikipedia's (somewhat labyrinthine) policies and guidelines. When addressing controversy in a Wikipedia article the quality of the sources and our accuracy in representing them is paramount. New editors should familiarise themselves with (at least) these policies if they want to understand where veteran editors are coming from:

• Wikipedia:Verifiability
• Wikipedia:Neutral point of view
• Wikipedia:Identifying reliable sources
  

--Anthonyhcole (talk) 04:49, 10 July 2012 (UTC)

Here I have edited the first paragraph and removed the more tabloid language. --Anthonyhcole (talk) 19:35, 12 July 2012 (UTC)

Also used on children and neonates

The article focuses on the elderly, but it is also used on newborns and children <http://www.dailymail.co.uk/news/article-2240075/Now-sick-babies-death-pathway-Doctors-haunting-testimony-reveals-children-end-life-plan.html?ito=feeds-newsxml>, again, ostensibly with the parents consent, UK law having been amended by Glass vs United Kingdom. <http://www.1cor.com/1315/?form_1155.replyids=344>, in which it was ruled to be an Article 8 Human Rights Act offence to administer diamorphine to disabled children against parents wishes (It was used on David Cameron's disabled son?? Should have been as it was a recommended care pathway at the time, which implies Cameron must have given his express consent-any sources?? )80.42.238.225 (talk) 03:06, 30 November 2012 (UTC)DrL03:06, 30 November 2012 (UTC)

Dead link

Wondering if anyone has a replacement for what was originally ref 3 or ref name=APM, http://www.palliative-medicine.org/default.asp Richiez (talk) 22:57, 4 December 2012 (UTC) Lots of documents are being revised and new ones uploaded by MC institute too, as well as the Association of Palliative Medicine...ahead of the review one imagines...CVs of those responsible for roll out across NHS and 22 other countries have also disappeared from webpages since the controversy hit the papers. 212.139.100.155 (talk) 10:53, 7 December 2012 (UTC)twl212.139.100.155 (talk) 10:53, 7 December 2012 (UTC)

Reasons For Adding Missing Information Message

The missing information template message was added 09:06, September 20, 2014, for the purposes of requesting a clear, clinical description of stages and specific protocols administered under LCP, hopefully as free of bias as possible. Specific protocols might be "no food or water provided," or "water allowed but no food," or some other description of what is given or not given to the patient in various stages of LCP. Without it this entire article only discusses the controversy surrounding it, dancing around the actual topic. There are "jack-in-the-box" references to the protocols (regimens) for LCP, like "sedation-and-dehydration regimes" under Controversy in Medical Issues, but no mention of this under Aims, which only briefly states:

The programme suggests the provision of treatments to manage pain, agitation, respiratory tract secretions, nausea and vomiting, or shortness of breath (dyspnoea) that the patient may experience.[5]

This is far from complete and sounds as if there's no point in helping people understand what care is given. Are the patients' needs for comfort specifically addressed, such as a dry mouth, chapped lips, bed sores, skin irritations, etc.? That would matter to me if I were to hear that my relative had been placed on LCP. Additionally, I would also wonder if the patient's emotional and spiritual needs are addressed. If the patient is feeling lonely and wants to talk to someone, is someone provided who can meet those needs? If the patient has specific questions about the end of life or afterlife, do they have access to a pastor or priest or lay counselor of their religion chosen? All of this matters to those who might have relatives under LCP or may one day face LCP themselves. Understanding what happens in LCP is fundamental to honest, truthful discussions about LCP. As an American living with a chronic condition, I find the lack of specifics about a British medical issue very troubling. Srwalden (talk) 15:54, 20 September 2014 (UTC)

It is my understanding that the pathway involves allowing the patient to dehydrate or starve whilst administering painkillers without concern that the dosages involved may shorten life or limit consciousness. Without making a judgement, the article is very incomplete without accurate information on this. Stub Mandrel (talk) 20:47, 13 March 2015 (UTC)

Copyright problem removed

Prior content in this article duplicated one or more previously published sources. The material was copied from: http://www.telegraph.co.uk/news/health/news/9644287/NHS-millions-for-controversial-care-pathway.html. Copied or closely paraphrased material has been rewritten or removed and must not be restored, unless it is duly released under a compatible license. (For more information, please see "using copyrighted works from others" if you are not the copyright holder of this material, or "donating copyrighted materials" if you are.) For legal reasons, we cannot accept copyrighted text or images borrowed from other web sites or published material; such additions will be deleted. Contributors may use copyrighted publications as a source of information, and according to fair use may copy sentences and phrases, provided they are included in quotation marks and referenced properly. The material may also be rewritten, but only if it does not infringe on the copyright of the original or plagiarize from that source. Therefore such paraphrased portions must provide their source. Please see our guideline on non-free text for how to properly implement limited quotations of copyrighted text. Wikipedia takes copyright violations very seriously, and persistent violators will be blocked from editing. While we appreciate contributions, we must require all contributors to understand and comply with these policies. Thank you. Justlettersandnumbers (talk) 00:40, 3 April 2015 (UTC)

In reading this article, it seems to carry a lot of personal viewpoints and is not very neutral. Is it just me? — Preceding unsigned comment added by 67.76.61.139 (talk) 07:39, 9 March 2016 (UTC)

Opening paragraph weasel words

The opening paragraph is contradictory. Old ladies have known what has been going on in "Our NHS" for years. The "Liverpool Care Pathway" started to be used (again) after "Whistle Blowers" exposed the practice of doctors overdosing patients (often with potassium) to finish them off in a peaceful and quick kind manor. Post Harold Shipman, doctors stopped carrying barbiturates on home visits (used for the same effect) to prevent any suggestion why it was carried. Starving and particularly dehydrating people was a well known way of dealing with problem cases. Anyone going into a hospital with elderly, especially those suffering from dementia still see the deliberate neglect of the most vulnerable. Nothing has changed, except doctors are now scared to carry out what are many peoples' final wish - to die peacefully, with dignity. The old are now cruelly neglected to death, too often before their time. — Preceding unsigned comment added by 79.70.4.39 (talk) 13:19, 9 September 2021 (UTC)

External links modified

Hello fellow Wikipedians,

I have just modified 5 external links on Liverpool Care Pathway for the Dying Patient. Please take a moment to review my edit. If you have any questions, or need the bot to ignore the links, or the page altogether, please visit this simple FaQ for additional information. I made the following changes:

• Added archive http://webarchive.nationalarchives.gov.uk/20120831174043/http%3A//www.endoflifecareforadults.nhs.uk/assets/downloads/LCP_response_to_media_Oct2009.pdf to http://www.endoflifecareforadults.nhs.uk/assets/downloads/LCP_response_to_media_Oct2009.pdf
• Added archive https://archive.is/20050415024953/http://www.palliative-medicine.org/default.asp to http://www.palliative-medicine.org/default.asp
• Added archive https://web.archive.org/web/20130301023518/http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/liverpool-care-pathway/updatedlcppdfs/LCP_Pocket_Guide_-_April_2010.pdf to http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/liverpool-care-pathway/updatedlcppdfs/LCP_Pocket_Guide_-_April_2010.pdf
• Added archive https://web.archive.org/web/20120907102923/http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/pdfs/lcpv12newdocuments/LCP%20Relative%20Carer%20Information%20Leaflet%20-%20Nov%2009.pdf to http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/pdfs/lcpv12newdocuments/LCP%20Relative%20Carer%20Information%20Leaflet%20-%20Nov%2009.pdf
• Added archive https://web.archive.org/web/20120907102858/http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/liverpool-care-pathway/updatedlcppdfs/What_is_the_LCP_-_Healthcare_Professionals_-_April_2010.pdf to http://www.liv.ac.uk/media/livacuk/mcpcil/migrated-files/liverpool-care-pathway/updatedlcppdfs/What_is_the_LCP_-_Healthcare_Professionals_-_April_2010.pdf
• Added {{dead link}} tag to http://healthguides.mapofmedicine.com/choices/map/end_of_life_care_in_adults1.html

When you have finished reviewing my changes, you may follow the instructions on the template below to fix any issues with the URLs.

This message was posted before February 2018. After February 2018, "External links modified" talk page sections are no longer generated or monitored by InternetArchiveBot. No special action is required regarding these talk page notices, other than regular verification using the archive tool instructions below. Editors have permission to delete these "External links modified" talk page sections if they want to de-clutter talk pages, but see the RfC before doing mass systematic removals. This message is updated dynamically through the template {{source check}} (last update: 18 January 2022).

• If you have discovered URLs which were erroneously considered dead by the bot, you can report them with this tool.
• If you found an error with any archives or the URLs themselves, you can fix them with this tool.

Cheers.—InternetArchiveBot (Report bug) 07:57, 4 January 2018 (UTC)

Liverpool 'Care' Pathway - a loaded term?

Let's be clear, the 'Liverpool Care Pathway for the Dying Patients' was always a loaded term - aimed at making the scheme sound fair and reasonable. Given this, why is Wikipedia helping to push a POV on what might to termed a small scale final solution? For if the this article is interested in ways of helping dying patients - and not just pushing a cost cutting agenda - might it not highlight the pressing need for decent and fully funded end of life care? — Preceding unsigned comment added by 95.151.2.22 (talk) 10:23, 3 May 2023 (UTC)