Wednesday, November 11, 2009

New Study Shows Patients Approve of Pathway.

From the Canadian Medical Association Journal (CMAJ) comes a story that sets all criticism (boy, would I love to see more informed, less ideologically-motivated writers refuting such bunk!) of the "Liverpool Pathway" straight:

It’s been lauded as an evidence-based framework for delivering appropriate end-of-life or palliative care to the terminally ill, and slagged a self-fulfilling proposition that should be known as the “Liverpool Death Pathway,” rather than the Liverpool Care Pathway.

A recent care audit given to dying patients in British hospitals, though, has reviewed the medical protocol favourably (

The controversial pathway, which was modelled on care provided at United Kingdom hospices for the terminally ill, was initially developed by the Royal Liverpool Hospital and the Marie Curie Cancer Care, a charity providing home or hospice care to terminally ill patients. Although initially developed for cancer patients, the program was later adapted for other conditions.

The pathway is meant to be applied during a dying patient’s last few days and hours. It offers guidance in such areas as symptom control, comfort measures, the discontinuation of inappropriate measures and anticipatory prescribing of medication, along with psychological and spiritual care of the patient and family.

“The Liverpool Care Pathway made physicians aware that the diagnosis of dying has consequences for what they did for patients,” says Dr. Bill Noble, president of the Association for Palliative Medicine of Great Britain. “Before this there was a tendency to simply carry on existing treatments until the patient could no longer endure them.”

(emphasis mine)

Many have long contended that when patients are given a choice in how and where they die, they approach death with less fear and anxiety, they are not subjected to "exhaust all options" treatments that seldom work, and the financial and resource burden on medical practitioners decreases. Rationing is one problem that could be alleviated by offering the elderly and terminal care choices at the end of life.

According to the study, the hospitals included show a heightened attention to end of life care, something that would make dying in the US a much less fearful prospect:

*The median number of side rooms has increased from 68 to 74 overall, and from 68 to 79 for those 104 hospitals in both audit rounds

*99% of hospitals have a Hospital Specialist Palliative Care Team

*75% of hospitals have a Coping with Dying Leaflet or equivalent available (compared with

58% in Round 1) and there has been an increase in the level of information available in


*84% of hospitals have an ongoing education programme for Nurses in care of the dying,

and 74% have such a programme for Medical Staff.

*An electronic data collection tool has been developed that enhanced the quality of

submitted data and streamlined the process of the audit.

The most important aspect of this study, however, and in my mind the most important indicator, is the satisfaction of patients and the honoring of their rights and informed consent:

The national audit which gave the pathway a favourable review was the second in two years conducted by the Marie Curie Palliative Care Institute and the Clinical Standards Department of the Royal College of Physicians, supported by the Marie Curie Cancer Care charity and the Department of Health End of Life Care Programme. The audit surveyed pathway use in 155 hospitals and examined the records of almost 4000 patients. Of hospitals surveyed, 74% said they had continuing education programs for doctors and 84% for nurses. But only 39% of hospitals had a facilitator to help staff implement the program.

The audit also found that the vast majority of patients were reported to be comfortable during their last 24 hours, with 65% needing no subcutaneous infusion of medication to control discomfort, 31% receiving low doses of subcutaneous medication and only 4% requiring higher doses.

I have some criticisms for the Liverpool Care Pathway but I'll leave those to another time. What I think is most positive about the plan is the attention it shows to end of life care, a rather heretofore neglected and notoriously under-researched or resourced aspect of patient care.

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