The withdrawal of the Liverpool Care Pathway by Britain’s National Health Service leaves Australian palliative care practitioners with a dilemma, according to a perspective published in the Medical Journal of Australia.
The LCP was designed in the 1990s to guide care for people with cancer who were in their last days of life and expected to die in hospital. It defined 18 goals of care relating to comfort, psychological and insight concerns, religious and spiritual support, communication with family and primary health-care teams, and care after death.
It rapidly evolved from a local solution to a local problem into a national program promoted by the UK’s NHS and adopted by more than 1800 health care institutions, without a sufficiently robust evaluation of its effectiveness.
In Australia, the LCP was used to develop the end-of-life care pathways (EOLCPs) that are now in widespread use across acute care hospitals and residential aged care facilities.
Dr Raymond Chan, a nurse researcher at the Royal Brisbane and Women’s Hospital’s Cancer Care Services, and his co-authors wrote that the UK’s decision to withdraw the LCP as a result of an adverse independent review created an urgent need for research in Australia.
“The lack of high-quality health services research before widespread implementation of the LCP … has created a dilemma for Australia: do the adverse findings [of the UK's independent review] apply to Australia and, if so, to what extent?” the authors wrote.
The UK review found the LCP was often associated with poor care and poor diagnosis of dying in clinical care, as well as ethical, safety, clinical practice and legal problems.
“Although the intention and end-of-life care principles underpinning the LCP are sound, use of the pathway has extended well beyond the evidence base”, the authors wrote.
Australian researchers need to establish whether the outcomes for dying patients placed on an EOLCP are different to those receiving usual care, and then answer several key questions:
- Are the right people put on an EOLCP at the right time?
- In which settings should an EOLCP be used?
- Who should have the authority to initiate an EOLCP?
- What specific medical history is required before initiating an EOLCP?
- How senior should the clinicians be and how much of the patient’s history should they know before initiating an EOLCP?
- Are there any differences in outcomes when comparing the different EOLCPs?
In the meantime, the authors wrote, Australian practitioners should review each of the shortfalls and adverse outcomes of the LCP highlighted by the UK review.
“We urge policymakers to continue to invest in building the palliative care capabilities of the Australian health care workforce”, they wrote.
“Ultimately, if the LCP is to be replaced, there needs to be systematic measurement of the benefits and harms generated by such a process.
“No intervention is without problems, and as a new process is implemented, the unexpected harms it may generate need to be measured so they can be overcome as they arise.”
?The withdrawal of the Liverpool Care Pathway in the United Kingdom: what are the implications for Australia? Raymond J Chan RN, PhD, FACN, Joan Webster RN, RM, BA, Jane Phillips RN, PhD, David C Currow BMed, MPH, FRACP, ?Medical Journal of Australia, DOI: 10.5694/mja13.10998, published 2 June 2014.
Medical Journal of Australia (MJA)