We agree with the notion that investment in “implementation and training- rather than developing guidelines from scratch” may be a better use of resources than completely withdrawing the Liverpool care pathway (LCP). We feel that this is particularly applicable when considering the use of fluid alongside the LCP.
Media coverage repeatedly highlights that withdrawal of artificial hydration is a primary concern for relatives who believe that this leads to death through dehydration (1). This was also emphasised by the Neuberger report (2). This is understandably distressing but when the rationale behind the use of artificial hydration is clearly communicated, anxiety and confusion can be alleviated. In order to explain this to patients and their families, we as doctors must first understand the rationale.
To get an idea of how well we as doctors understand fluid use alongside the LCP, we surveyed 50 junior doctors in a medium-sized district general hospital in Somerset where there is an ever growing elderly population. 20% held the incorrect view that withholding artificial hydration speeded up the time to death by precipitating dehydration. Conversely, 30% believed that providing artificial hydration improved survival and thus prolonged suffering. 35% thought that when initiating the LCP, a blanket policy of stopping intravenous (IV) fluids and starting subcutaneous (SC) fluids should be adopted whilst 20% thought that IV fluids should automatically be stopped with no further consideration given to hydration. 55% recalled at least one occasion when senior staff (registrar or consultant) had adopted a blanket policy, with a tendency towards routinely prescribing subcutaneous fluids, rather than considering the use of artificial hydration on an individual patient basis.
We then went on to investigate how well explained fluid use alongside the LCP was. To do this we audited the notes of 100 patients placed on the LCP between October 2012 and April 2013, and found that communication with relatives prior to starting the LCP was documented in 98%. In the remaining 2%, relatives were not contactable. When looking specifically at artificial hydration, we found that 22% received this in some form (either IV or SC) while on the LCP which on subsequent review was then stopped. In stark contrast, only 5% of these cases had any written documentation of a conversation with relatives regarding discontinuation of artificial hydration. This implies that although communication with relatives regarding initiation of the LCP may be better than conveyed in the media, specific discussion around the use of artificial hydration is being neglected. Given that this is such an important concern to the public, conversations about food and fluid must be a priority to put families at ease and to stop fuelling the misconceptions.
As the “LCP: a cautionary tale” article highlights, we need further research into how we can optimise outcomes and experiences of patients and their families who experience end of life care. Ultimately the new end of life care plans will use the same supportive medications as used in the LCP, however the greatest changes will be in the approach to communication with patient and their families as well as the review of patients when approaching end of life. Good communication and explanation of fluid use in the end stages of life will ensure that medication side effects are not mistaken for dehydration and that the multidisciplinary team know that food and fluid should be offered to all patients unless the risks outweigh the benefits.
Ultimately, the LCP was only as good as the people using it.
REFERENCES
1) Chapman S, Sutton L, Richardson E (2007). Artificial Nutrition and Hydration – Summary Guidance. National Council for Palliative Care. ISBN 978-1-898915-54-6
2) More care, less pathway. A review of the Liverpool Care Pathway. Baroness Neuberger et al. 15th July 2013
Rapid Response:
Re: The Liverpool care pathway: a cautionary tale
We agree with the notion that investment in “implementation and training- rather than developing guidelines from scratch” may be a better use of resources than completely withdrawing the Liverpool care pathway (LCP). We feel that this is particularly applicable when considering the use of fluid alongside the LCP.
Media coverage repeatedly highlights that withdrawal of artificial hydration is a primary concern for relatives who believe that this leads to death through dehydration (1). This was also emphasised by the Neuberger report (2). This is understandably distressing but when the rationale behind the use of artificial hydration is clearly communicated, anxiety and confusion can be alleviated. In order to explain this to patients and their families, we as doctors must first understand the rationale.
To get an idea of how well we as doctors understand fluid use alongside the LCP, we surveyed 50 junior doctors in a medium-sized district general hospital in Somerset where there is an ever growing elderly population. 20% held the incorrect view that withholding artificial hydration speeded up the time to death by precipitating dehydration. Conversely, 30% believed that providing artificial hydration improved survival and thus prolonged suffering. 35% thought that when initiating the LCP, a blanket policy of stopping intravenous (IV) fluids and starting subcutaneous (SC) fluids should be adopted whilst 20% thought that IV fluids should automatically be stopped with no further consideration given to hydration. 55% recalled at least one occasion when senior staff (registrar or consultant) had adopted a blanket policy, with a tendency towards routinely prescribing subcutaneous fluids, rather than considering the use of artificial hydration on an individual patient basis.
We then went on to investigate how well explained fluid use alongside the LCP was. To do this we audited the notes of 100 patients placed on the LCP between October 2012 and April 2013, and found that communication with relatives prior to starting the LCP was documented in 98%. In the remaining 2%, relatives were not contactable. When looking specifically at artificial hydration, we found that 22% received this in some form (either IV or SC) while on the LCP which on subsequent review was then stopped. In stark contrast, only 5% of these cases had any written documentation of a conversation with relatives regarding discontinuation of artificial hydration. This implies that although communication with relatives regarding initiation of the LCP may be better than conveyed in the media, specific discussion around the use of artificial hydration is being neglected. Given that this is such an important concern to the public, conversations about food and fluid must be a priority to put families at ease and to stop fuelling the misconceptions.
As the “LCP: a cautionary tale” article highlights, we need further research into how we can optimise outcomes and experiences of patients and their families who experience end of life care. Ultimately the new end of life care plans will use the same supportive medications as used in the LCP, however the greatest changes will be in the approach to communication with patient and their families as well as the review of patients when approaching end of life. Good communication and explanation of fluid use in the end stages of life will ensure that medication side effects are not mistaken for dehydration and that the multidisciplinary team know that food and fluid should be offered to all patients unless the risks outweigh the benefits.
Ultimately, the LCP was only as good as the people using it.
REFERENCES
1) Chapman S, Sutton L, Richardson E (2007). Artificial Nutrition and Hydration – Summary Guidance. National Council for Palliative Care. ISBN 978-1-898915-54-6
2) More care, less pathway. A review of the Liverpool Care Pathway. Baroness Neuberger et al. 15th July 2013
Competing interests: No competing interests