What is the Liverpool Care Pathway?

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I'd never heard of the Liverpool Care Pathway until it hit the news.

As it turns out, it is the name of a legally constituted program within hospitals in the UK to allow euthanasia of the elderly under certain circumstances.

Introduced or legislated for in 1996, it resolved a legal problem for terminally ill patients, their family, and the medical profession.

Helping someone to die comfortably is humane, and has been practised in hospitals for years, if not forever.

When someone is within days of dying, in pain and in severe discomfort, death is a blessing to them.

It's an end to their misery.

Caring doctors and nurses can't wave a magic wand and make it all better, much as they'd like to.

The absolute best they can do is to make sure that person is comfortable, pain-free, and never left alone.

When I was a young nurse in the 1970s, we did everything we could to keep people alive, because we cared.

Even so, there came a time when death was inevitable.

Death IS inevitable for all of us. When it is imminent, the best we can do is make sure those last hours are pain-free for those in our care.

Morphine was and still is, the most powerful pain-killer known to man.

Unfortunately, it also depresses the respiratory system.

When the respiratory system is depressed, breathing is more difficult and we are more prone to chest infections.

It can kill a terminally ill patient.

People in pain, and many cancers are extremely painful, deserve the most powerful analgesic available.

They not only deserve it, they need it, because nothing else will touch their pain.

We effectively hastened their deaths by giving them diamorphine (a mixture of morphine and heroin) injections.

We knew we were doing it, but we did it for the best of reasons; to ensure a comfortable and smooth passage between this world and the next.

I will never regret any of those injections I gave (under medical prescription) to those people.


If this level of care existed, why was a new procedure brought out - The Liverpool Care Pathway?

I have absolutely no idea, considering it has been many years since I have been nursing.

If it has always been the case that caring nurses and doctors treated patients to the best of their abilities, and gave them an extra level of care when they were dying, why did this procedure suddenly get a name?

The only two things I can think of is that:

a) litigation has increased, and without a legally agreed procedure in place, someone might choose to sue.

b) All those university trained nurses might have preferred to have a written care plan to follow.

In my day, nurses were trained on the wards, with interludes of college lessons on campus. The advantage of ward trained nurses include the weeding out of non-caring people. Nurses learned their jobs through watching and assisting professionals at work.

Some things just can't be taught at university.


The wording of the care Pathway

According to the NHS Foundation Trust, the Liverpool Care Pathway is a means of recording the care given to a dying patient.

Once someone is put on the plan, everything is controlled by paperwork, by the ticking of boxes to ensure the plan is followed to the letter.

Each hospital has a Care Pathway team, and it is they who decide the fate of any elderly patient who is admitted.

This decision is taken according to the forms drawn up.

The general health of the patient as well as prognosis is taken into consideration.

If the team agrees that the patient is dying, they may be put on the Liverpool Care Pathway if they have just two of the following conditions:


  1. The patient is bedbound
  2. Semi-comatose
  3. Only able to take sips of fluids
  4. No longer able to take tablets



The Terminal Care of the Patient


  • The turning of the patient, which is routine in hospitals to prevent pressure sores, is only carried to out to make the patient comfortable, if done at all.

[ Some people have apparently recovered after having been put on the Liverpool Care Plan, only to need prolonged treatment for the pressure sores they developed while on it.]

  • Mouth care should be given at least 4 hourly.

[Some hospitals are missing this bit out and giving no oral hygiene, not even a comforting water-filled sponge for patients to suck on.]

  • No medication designed to prolong life should be given.

[This would include any medications previously prescribed for existing conditions like hypertension or diabetes.]

  • All oral medications should be converted to subcutaneous (under the skin injections), or syringe driven injections.

[Even those who can still swallow tablets and are not semi-unconscious.]

  • All blood tests stopped, and antibiotics and IV fluids withdrawn.


  • 4 hourly observations should be taken and recorded to ensure the patient is clean, dry and comfortable. A urinary catheter may be inserted if patient is incontinent or suffers from urinary retention.


  • If the patient is diabetic, blood glucose levels should be checked once daily.


  • The patient's family should be informed of procedures, and kept updated as to their relatives progress.


  • Ensure that the patient's spiritual needs are met. If Catholic, see that the priest comes into perform the Last Rites. If other religion, ensure that the appropriate body is contacted and final prayers or arrangements dealt with.


Medication for the dying patient on the Liverpool Care Pathway

PAIN

If in pain, they are given morphine in the form of diamorphine. If they already on oral medication, this is changed to intra-venous via a syringe driver.

If they are NOT in pain, they are prescribed diamorphine via syringe driver.

RESTLESSNESS AND AGITATION

If they have terminal restlessness and agitation, they are given MIDAZOLAM 2.5 - 5mg subcutaneous prn. If they live longer than 24 hours, this is changed to a syringe driver.

If they DO NOT have terminal restlessness and agitation, they are given the same medication as above.

RESPIRATORY TRACT SECRETIONS

If they have respiratory tract secretions, they are given HYOSCINE HYDROBROMIDE 0.4mg s/c bolus injections. This is changed to a syringe driver if they live longer than 24 hours.

If they DO NOT have respiratory tract secretions, they are to be given the Hyoscine anyway, as above. (Hyoscine dries up all liquid secretions in the mouth and throat, so mouth care will need stepped up - this is not mentioned in the care plan).

NAUSEA AND VOMITING

If they have NAUSEA and VOMITING, they are to given Cyclizine 50mgs S/C bolus injections, changed to syringe driver after 24 hours.

If they DO NOT suffer from nausea and vomiting, they are to be given the same treatment as above, as if they do.

Patients with heart failure get a different drug - either Haloperidol s/c 2.5 – 5mg or Levomepromazine s/c 6.25mg.

DYSPNOEA

Dyspneoa (breathlessness)

If the patient has difficulty breathing, they are given diamorphine 2.5 - 5mg prn via syringe driver.

If their breathing is fine, they are given the same dosage.


This is called ANTICIPATORY PRESCRIBING and should ensure that your loved one passes away peacefully with no discomfort.


You will note that no provision is made for food and water, both of which are necessary for sustaining life.


Am I the only one not liking this?

The Liverpool care Pathway applies only to elderly people admitted to hospital after having suffered a fall, a stroke, an infection or any of the other multitude of things that cause our elderly to end up in hospital.

It would seem that within hours of admittance, after a check-over by strangers, your mother or father could be 'put to death' in this way.

They cannot possibly know your parents, nor their level of health impairment up to this point.

Year ago, when I was nursing, we fought to keep all of our patients alive, elderly or not.

It was only have weeks of care when we saw someone slip rapidly downhill, and the results of all the tests we carried out confirmed their life was close to an end, that we initiated a helping hand to ensure their passage was as comfortable and pain-free as we could make it.

NOW under this 'care regime', elderly people are being singled out for this exclusive care, that includes the administration of a powerful concoction of medications designed to hasten, or cause, their demise.


Cost of Residential Care of the Elderly in the UK

In the UK, it has long been a problem for the National Health Service that something like 1 in 2 acute hospital beds are taken up by an elderly person, who is need of basic nursing care and not much else.

Nursing homes and care of the elderly homes welcome our old people, so long as they are basically well and not incontinent.

As privately-owned concerns, most of these establishments do very nicely from the money paid to keep old folk in one of their residential care homes, at a starting price of £700 ($1120) per week per person.

An NHS bed costs £400 ($640) per day, paid for by the tax-payer, as of 2012.

Cash-strapped NHS hospitals must dread the admittance of an elderly person.

Time for Families to Take Care of their own?


I am sick of hearing and reading about the ill-treatment handed out to our elderly in care homes by under-qualified, under-paid and frankly uncaring staff.

So much so, that I vowed never to allow my own parents, now in the 80s, to go into one of these so-called 'care establishments'.

After all, these same people cared for us when we were babies, and gave up quite a few years of their lives to bring us up.

The least we can do is return the compliment.

Now, with the threat of the dreaded Liverpool Care Plan hanging over all our heads (we all grow old and die, it is a fact of life), I don't want to see Mum and Dad go into hospital either.

If they do have to at some point, at least many of us are now aware of exactly what this Liverpool Care Pathway is, should they dare try to put our own old folk on it before they are ready to die.

Obamacare?

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Comments 13 comments

mperrottet profile image

mperrottet 3 years ago from Pennsauken, NJ

This sounds like a dangerous program to me, and I can see your concern. I live in the U.S. My father died at 95, but was in and out of nursing homes and hospitals for 5 years before that with urinary tract infections that nearly killed him each time. He pulled through them, and lived a good life in between these battles. It seems to me that under these rules if we were in England, he would have been basically "put out of his misery" during the first bout of infection, thus robbing him of 5 years of a life that he fully enjoyed. Good hub - voted up!


Judi Bee profile image

Judi Bee 3 years ago from UK

Not heard about this at all - it's terribly worrying. Are the families informed of the plan? It does sound like the plan put into place for my mother's last days. She died at home (which was then in the US), but we were fully aware that she had reached the end of her battle with cancer and everything was clearly explained to us.


IzzyM profile image

IzzyM 3 years ago from UK Author

Families are supposed to be informed, but in many instances it is not explained to them, and they are not told their relative is on it. That is a HUGE failing.

Judi, your mum may well have been on it, or the US equivalent of it, but it looks like in your mother's case the program was used correctly as your mother had cancer and was dying already. I am really sorry to hear you lost your mother :(

The LCP is designed to bring about a peaceful death and was initially aimed at cancer victims where once they are in a coma, as many are, the withdrawal of sustenance would not be noticed so much, and the increase of painkillers would be welcomed. It was not designed to kill off elderly people who are ill but not terminally, like mperrottet's father, who I'm glad to hear had an extra 5 years after his health started failing.

Thank you both for commenting.


writer20 profile image

writer20 3 years ago from Southern Nevada

Izzy, I have believe in euthanasia since the 70's when I still lived in England for people that are in pain and nothing can help them.

Voted up useful and very interesting, Joyce.


IzzyM profile image

IzzyM 3 years ago from UK Author

Thanks Joyce, but decisions over euthanasia should be taken by the patient in conjunction with their GP and family, not by stressed out hospital consultants who only want to free up a bed. You would never dream of putting down an old lady just because she developed a UTI or fell and broke a bone, yet that seems to be happening, That is someone's mother and she should be treated with dignity. I see little dignity in this.


CASE1WORKER profile image

CASE1WORKER 3 years ago from UNITED KINGDOM

Izzy I think we might have read the same article and I guess we have the same reservations and a certain feeling that it is not well. No one should be excluded from fluids just to die a few days earlier and save cash. Like you I have always said that I would look after my mother at home, but unlike you this resoution has not been put to the test. Hospitals are there as a last resort in my opinion and you need to be well to cope ( which obviously you are not in the first place or you would not be there) Liverpool care pathway- even the name sounds dubious- great idea to let the word know about what goes on in the UK


IzzyM profile image

IzzyM 3 years ago from UK Author

Thanks, Case :) I am also working on another hub outlining details of individual cases that have have already hit the news. I wish I'd known about this before. Then again, so do a lot of people and it is too late for them. Yes the Daily Mail have carried some stories on this, as have the Telegraph and I will search to see who else. It is the withdrawal of fluids that gets me more than anything, more so even than the lethal cocktail of drugs given. To me, that is murder. Taking away modern life-saving medicine or interventions like life-support is one thing. It is another entirely to take away the very sustenance of life itself.

I remember a case a few years ago of a young patient who was unconscious on life support. After a long battle lasting maybe a couple of years, the family in conjunction with doctors agreed to turn the machine off. But the patient didn't die. He continued breathing on his own. So the doctors decided to withdraw food and went to court over it. I was shocked when the courts agreed. The patient duly died without food and water. It's wrong because unlike drugs or interventions, we all need food. We can last months without it, but only days without water. It's a basic human right to have them, a bit like the air we need to breathe.


annart profile image

annart 2 years ago from SW England

This is very unsettling. I knew nothing about this 'plan'. I'm of course aware that obviously dying patients are given medication to assist a comfortable death where possible but this seems to hasten a few and indeed be administered to some who might not even need it.

As for the food and water bit, as you say, it's a basic human right and it's not difficult to give!

I agree with you 100% that nurses should be given more practical experience, like they used to have with a ward matron who ruled with a rod of iron! Nothing to beat 'hands-on' practicalities and demonstration.

This is a well-presented and extremely informative hub. I shall keep my ears open for any mention of this and I'll certainly alert my children, just in case I'm in that situation one day!

Up, interesting and v v useful.


IzzyM profile image

IzzyM 2 years ago from UK Author

Thanks annart :) I think I saw a newspaper headline a couple of weeks ago that said the government is withdrawing the Liverpool Care Plan after complaints, but need to read more into it to learn if they have actually done it, or are just contemplating doing it.


annart profile image

annart 2 years ago from SW England

I'd be interested to see what you find out.


IzzyM profile image

IzzyM 2 years ago from UK Author

I didn't have to search far before I came across fresh articles on the subject.

This one made my blood boil - http://www.telegraph.co.uk/health/10421787/Liverpo...

The idiot doctor in it gave IV fluids to a dying geriatric patient and was shocked when his 'care' made things worse. No surprise there. His opinion should count for nothing because obviously his training was lacking.

Even worse, I then found this more recent article - http://www.telegraph.co.uk/health/healthnews/10487...

OK same site, but Google must like them to place them highly in the SERPS.

Read it. It makes me want to cry.

They took the Liverpool Care Pathway away, and are replacing it with something WORSE!

My father has died since I wrote this article. He died in the local hospital having walked in that morning. They treated him for something, but it was something else completely different. They never gave him morphine when he asked for it and he should have been given it. They gave him it after he collapsed, but he was already unconscious by then so all it did was hasten his death. I complained to the Health Board, but of course the doctors in question had answers. It was the nurses I really had issue with. Lazy B's sitting around the station and giving my Dad paracetamol when he was in agony. Common sense has flown with the new regime of university trained nurses and no matron.

Sister of old would have known what was wrong and what to do, but not this lot! My Dad took about 5 hours to die. He was unconscious, but he lay there, cold to the touch. I had to ask the nurses for blankets for his bed! I shouldn't have had to.

Now I have Mum, and she really needs nursing care for her dementia, but I will not pass her over to them. I'm being run ragged taking care of her, and I am getting no help except for one day's day care per week. They can't take her more often because they do not have the staffing or the funds, despite the doctor saying she should have two days. There is supposed to be free 'personal care' for the elderly in Scotland, but I am getting none of it. Physically she is fit. I am reluctant to put her into care, because they could 'Liverpool Care Pathway' her. I do not trust any of them to have my mother's best interests at heart.


sallybea profile image

sallybea 2 years ago from Norfolk

IzzyM - I help care for an elderly lady who shows early signs of dimentia. She recently had a fall where it took two weeks for her to be diagnosed with a fractured lower spine. She was almost admitted to a home because the family were unable to cope with her care. The whole thing was handled with only one thing in mind, the budget, or lack of it to care for her. It is an absolute disgrace. Our old folk are not being dealt with in a humane way at all. It makes my blood boil, just thinking about it.

Thanks for highlighting this.


IzzyM profile image

IzzyM 2 years ago from UK Author

That is shocking, Sally. She should have been given an X-ray as a matter of routine after her fall. The elderly break bones very easily.

Since I wrote this hub, my mother has become a helpless geriatric due to dementia. There is help out there, providing I am prepared to pay for it. What the Hell? NHS was meant to cover care from cradle to grave.

Free personal care is supposed to be available in Scotland, but no-one can tell me how it works. I am my mother's live-in carer and it is a constant 24 hour a day slog. I can't leave her on her own for 2 minutes, never mind getting some time off, but I still don't want her put down like a dog. She's still my Mum even if she thinks I am her granny. The NHS and Social Work will be responsible for two bodies in a grave if they can't get their act together.

The Liverpool Care Pathway was no doubt set up to save the lives of family carers, but it was still wrong. They need to find the money to give real help to people like me and my mother. Putting one to death is not the answer.

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