REPORT TO TRUST BOARD
Date: 30th September 2013
Agenda No: 6.5
Title of Document: Independent Review of the Liverpool Care Pathway
Report Author: : Dr Debra Swann, Palliative Medicine Consultant; Caroline Adams, Clinical Nurse
Specialist Palliative Care, Edward Adams, Director of Corporate Governance
Lead Director: Zoë Packman, Director of Nursing, Midwifery and AHPs
Steve Ebbs, Medical Director
Summary: The Liverpool Care Pathway for the Dying Patient (LCP) was implemented at Croydon
University Hospital (CUH) in 2007, as best practice for guiding and documenting adult end of life care.
The report “ More Care Less Pathway – A Review of the Liverpool Care Pathway” was published by an
Independent Review panel, chaired by Baroness Julia Neuberger, in July 2013. The review
recommends that the LCP be phased out within the next six to twelve months and is replaced with an
end of life care plan.
The palliative care team at CUH consulted with the Croydon Consultant’s committee, the Quality and
Clinical Governance committee and a lay member of the Croydon End of life care committee, about
continuing to use version 12 of the LCP until an appropriate alternative is available. There was full
support from all of those consulted with their suggestions incorporated into this final report.
Until national proposals are produced for a new framework, Croydon proposes to continue to use the
latest version of the LCP (version 12), subject to stringent safeguards, notably that the decision to place
a patient on the LCP will be taken by the patient’s Consultant, having discussed this with the patient
(where possible) and the patient’s family and that the family are in agreement. CHS staff training will
include priorities for the care of patients at the end of life across all clinical staff, and the Trust will work
towards providing a seven day a week face to face specialist palliative care service with on-going
provision for advice out-of-hours.
In accordance with the recommendations of the Neuberger Committee that a lay Board member should
lead take responsibility for the care of dying patients across the Trust, Godfrey Allen will assume this
responsibility in Croydon.
Recommendations:
1. CHS will continue to use V12 LCP as a framework for managing the end of life care for patients
who are in the last few hours/days of life. With the provision that this decision has been made
by their consultant, and where their consultant has discussed LCP with their family, and where
family are in agreement.
2. CHS will follow any national recommendations as they are released for guidance in end of life
care.
3. The LCP framework will be discontinued when a viable alternative is provided nationally.
4. CHS clinical staff will receive training on priorities for the care of patients at the end of life.
5. CHS will work towards providing a seven day a week face to face specialist palliative care
service with on-going provision for advice out-of-hours.
Corporate Objectives - Corporate Objectives :
This serves the objectives both of delivering high quality, integrated and patient-centred care (SO1) and
working with partners to improve the health and wellbeing of the people of Croydon (SO5)
Who has been consulted in the production of this report:
Proposal was agreed by EMB on 11th September
Has an equality impact assessment (EIA) form been completed?
report
Not applicable for this
If not applicable, Please state why an EIA is not applicable. This document applies to all adult
patients treated at the end of life by CHS.
Has legal advice been taken?
report
Does this report have any financial implication?
If so, has the report been approved by the Finance Directorate?
Key Risks:



Risks reflected in Corporate Risk Register Yes/No
Not applicable for this
No
Independent Review of the Liverpool Care Pathway
The Liverpool Care Pathway for the Dying Patient (LCP) was implemented at Croydon University
Hospital (CUH) in 2007, as best practice for guiding and documenting adult end of life care. The most
recent LCP document, Version 12 LCP, was implemented across the hospital in Summer 2012.
The report on the findings of the Independent Review of the LCP chaired by Baroness Julia Neuberger
was published July 2013. Version 12 LCP began to address some of the concerns subsequently raised
in the Neuberger Report, particularly in relation to nutrition and hydration at the end of life. However, the
review recommends that the LCP be phased out within the next six to twelve months and is replaced
with an individualised end of life care plan.
As an interim, we propose that CUH will continue to use Version 12 of the LCP as a framework to
provide patient and family centric end of life care for those patients who meet the criteria for the pathway,
whilst an alternative is developed. Use of the LCP will be phased out when a viable alternative is
agreed. The new framework will be implemented by the Palliative Care Team. The Palliative Care
Team strongly believe that abrupt withdrawal of Version 12 LCP will create a greater risk that poor
quality end of life care may be delivered by CHS, than continuing to use Version 12 LCP with the
caveats proposed in this report.
Therefore, the Palliative Care Team recommend to CHS that our holding position will involve continuing
to use Version 12 LCP where the decision to start the pathway is made by the managing consultant or
GP in discussion and agreement with patient, where possible, and family. We have advised teams to
have a very low threshold for referring dying patients to palliative care, whether or not they have
specialist palliative care needs. We have modified our practice, that if families express any concern
about implementing the document (Version 12 LCP) we will ensure that good quality end of life care is
provided without the framework in place. In the short term, we will audit month by month those patients
cared for using Version 12 LCP ensuring documented discussion took place with patient and family by
the consultant that the patient is approaching the end of life, with the rationale for using the document,
and that regular review took place.
Interim arrangements:
We have recommended that for all patients cared for using the LCP framework, teams must:
 Ensure that any decision to put any patient on the LCP is made only by a consultant who best knows
the patient following a face to face assessment, in consultation with the patient (wherever possible)
and family/carers, and other members of the multi-professional team.
 Ensure that the decision to place the patient on the LCP has been discussed with and agreed with
the patient (if possible) and family if patient is not able to have that conversation
 Ensure that the patient’s family is aware that the patient is on the LCP, understands the reason and
purpose of this, and agrees with this decision.
 Continue to reassess the patient regularly and frequently.
 Ensure a consultant review of the decision for the patient to remain on the LCP, ideally by the
consultant and team who best know the patient.
 Communicate with the patient (wherever possible) and family/carers regularly to address questions
or concerns about any aspect of care, or the LCP itself.
 If a patient remains on the LCP, continue to implement it properly. This includes regular
assessments, symptom control and comfort measures (including offering oral fluids and good mouth
care), communication with the patient and family/carers, and provision of psychological, social and
spiritual care.
 If a patient comes off the LCP, continue to pay attention to, and address, symptom control, comfort
measures, and psychological, social and spiritual care, alongside any other treatment.





Reassess the patient regularly and frequently so that the care plan can be adjusted, taking into
account the patient’s wishes (where known) and family’s views, especially their knowledge of the
patient’s wishes.
For patients who are not cared for using the LCP but who are likely to die within the next few days,
doctors and nurses must:
Assess the patient regularly and frequently so that an end of life care plan can be made or adjusted,
taking into account the patient’s wishes (where known) and families’ views.
Communicate with the patient (wherever possible) and family/carers regularly to address questions
or concerns about any aspect of care. In particular, families need to be warned if the patient is likely
to die in the next few days or hours, so that they have time to begin preparing themselves.
Continue to pay attention to, and address, symptom control and comfort measures (including offering
oral fluids and good mouth care), and provision of psychological, social and spiritual care.
It is established CUH practice that patients cared for at the end of life may continue, start or stop
clinically assisted hydration and/or nutrition with all decisions made in an individual’s best interests, in
line with the Version 12 LCP framework.
Because of heightened awareness about the LCP at the moment, there may be increased anxiety.
Professionals should go out of their way to check if patients and their families have any concern about
their end of life care, whether or not the Liverpool Care Pathway is being used. There should be a very
low threshold for referral to the specialist palliative care team for end of life care advice.
Next Steps
The individual recommendations of the Neuberger Report requiring a local response by Croydon
Health Services NHS Trust are listed below. There are additional recommendations awaiting
national guidance.
Neuberger Recommendations
7. Falsification of documentation:
Clinicians should be reminded by their
registration bodies that the deliberate
falsification of any document or clinical record,
in order to deflect future criticism of a failure of
care, is contrary to GMC and NMC guidelines,
and therefore a disciplinary matter.
CHS Position
GMC and NMC standard
Responsibility
All staff
14. Decisions to initiate an end of life care
plan out of hours : Every patient diagnosed as
dying should have a clearly identified senior
responsible clinician accountable for their care
during any ‘out of hours’ period. Unless it is
unavoidable, urgent, and is clearly in the
patient’s best interests, the decision to
withdraw or not to start a life-prolonging
treatment should be taken in the cool light of
day by the senior responsible clinician in
consultation with the healthcare team. The
practice of making such decisions in the middle
of the night, at weekends or on Bank Holidays,
by staff that do not have the requisite training
and competence, should cease forthwith.
Established CUH practice that
decision to start LCP is made by
Consultant, in consultation with
MDT, in line with Version 12
(V12) LCP framework
Underpinned by consistency
across palliative care teaching,
highlighted by National Care of
the Dying Audit of Hospitals3
(NCDAH3). Snapshot audit after
Report publication of most recent
CUH LCP deaths: decision to
start LCP made and documented
by consultant in all 9 cases
reviewed
All Consultants
19. Nutrition and hydration:
All staff in contact with patients should be
trained in the appropriate use of hydration and
nutrition at the end of life and how to discuss
this with patients, their relatives and carers.
It is established CUH practice
that patients cared for using LCP
may continue, start or stop
clinically assisted hydration
and/or nutrition with decisions
made in an individual’s best
interest. In line with V12 LCP
framework.
 Underpinned by
consistency across
palliative care teaching,
highlighted by NCDAH(3).
20. Nutrition and hydration:
There should be duty on all staff to ensure that
patients who are able to eat and drink should
be supported to do so

All staff are reminded that
wherever possible patients
should be helped to eat and
drink for as long as possible
21. Nutrition and hydration:
Failure to support oral hydration and nutrition
when still possible and desired should be
regarded as professional misconduct

23. Sedation and pain relief:
Before a syringe driver is commenced, this
must be discussed as far as possible with the
patient, their relatives or carers, and the
reasoning documented.

Failure to support oral
hydration and nutrition would
be considered as professional
misconduct and will be
reported via the appropriate
channels
Junior doctor induction
includes training on symptom
control at the end of life
(EOL) including indications
for use of syringe driver and
medications for symptom
management at the end of
life.
Regular trained nurse study
sessions also include this
training.

24. Sedation and pain relief:
New research is needed on the use of drugs at
end of life, and in particular on the extent to
which sedative and analgesic drugs themselves
contribute to reduced consciousness, and
perceived reduction of appetite and thirst.
Anticipatory prescribing of
symptom management
medications at the end of life on
a prn basis is best practice. The
National Care of the Dying Audit
of Hospitals (2) looked at
prescribing and use of symptom
meds in last 24 hours of life.
All staff
All clinical staff
(medical,
nursing and
support team)
Medical
director and
director of
nursing
All doctors
All nurses
Palliative Care
Team
CUH results: 93% patients on
LCP had Midazolam prescribed
prn. Only given in 11% of the
patients, (median dose 2.5mg),
57% of patients on LCP were
prescribed a syringe driver.
53% of those syringe drivers
contained Midazolam (median
dose 10mg/24 hours)
25. Financial incentives:
There is no payment per patient
Trust
Payments ‘per patient implemented on the
LCP, or equivalent approach’ should cease.
or equivalent approach at CUH.
The palliative care consultant
negotiated to exclude this
measure from the 2011/12
EOLC CQUIN indicators
26. Accountability:
A named consultant or GP, respectively, should
take overall responsibility for the care of
patients who are dying in hospital or the
community.
All consultants understand that
they are responsible for their own
patients who die in the Trust.
This was reiterated at the
Consultant’s committee meeting
on22.08.13 by Dr Swann
All Consultants
(GPs for
community
patients)
27. Accountability: The name of a registered
nurse responsible for leading the nursing care
of the dying patient should be allocated at the
beginning of each shift. This nurse will be
responsible also for communicating effectively
with the family, checking their understanding,
and ensuring that any emerging concerns are
addressed.
Named nurse system in place on
all adult wards
Ensure the named nurse is made
known to the patient/family at the
start of each shift
Ensure all trained nurses aware
of the importance of responsibility
for each dying patient and their
family on a named nurse basis
Director of
Nursing
28. Accountability:
The boards of healthcare providers providing
care for the dying should give responsibility for
this to one of its members – preferably a lay
member whose focus will be on the dying
patient, their relatives and carers – as a matter
of urgency. This is particularly important for
acute hospitals.
CHS Executive Board to appoint
a lay member to be responsible
for care of dying patients across
the Trust.
 Godfrey Allen (Chair of
the Quality and Clinical
Governance Committee)
has agreed to undertake
this role

Snapshot audit after Report
publication of most recent CUH
LCP deaths: discussion about
dying, prognosis and LCP made
and documented by consultant or
STR in all 9 cases reviewed.
Family agreement documented in
all 9 cases
Established CUH practice that
decision to start LCP is made by
Consultant, in consultation with
MDT, in line with V12 LCP
framework
Underpinned by consistency
across palliative care teaching,
highlighted by NCDAH(3).
Chair of
Executive
Board
29. Documenting an end of life care plan:
Guidance should specify that the senior
clinician writes in the patient’s notes a record of
the face to face conversation in which the end
of life care plan was first discussed with the
patient’s relatives or carers. The record of that
conversation must include the following:
That the clinician explained that the patient is
now dying and when and how death might be
expected to occur.
If the family or carers do not accept that the
patient is dying, the clinician has explained the
basis for that judgement.
That the relatives or carers had the opportunity
to ask questions.
30. Documenting an end of life care plan:
To be developed when National
A shared care folder, kept at the hospital
guidance on replacing LCP is
bedside and designed for communication
available
between patients, relatives and the staff, should
be introduced, supported by training for staff on
All consultants
Palliative Care
Team will full
support of
Trust
how to use it.
31. Documenting an end of life care plan:
There should be better integration in the
community between LCP or other similar
documentation and the existing system of
shared care folders, so that the care provided
by relatives and carers (professional or
otherwise) is noted, and their contribution is
incorporated into documentation.
Croydon Community service to
continue to follow CHS guidance
which is to use the LCP where
patients are known to community
palliative care services.
32. Independent advocacy:
For each patient on an end of life care plan that
has no means of expressing preferences and
no representation by a relative or carer, views
on their care should be represented by an
independent advocate, whether appointed
under the Mental Capacity Act 2005, a
chaplain, or an appropriate person provided
through a voluntary organisation. This applies
to people of whatever age who lack capacity.
Croydon IMCA Service involved
as needed
33. Availability of palliative care support:
Funding should be made available to enable
palliative care teams to be accessible at any
time of the day or night, both in hospitals and in
community settings, seven days a week.
Mon-Fri 9-5 face to face service
provided by CUH palliative care
team. OOH telephone advice
provided day/night/weekends/
BH by St Christopher’s Hospice
on-call Consultant.
-Plans underway to pilot an
extended 6 day/week 9-5 face
to face service by CNSs by end
2013.
Trust
37.Guidance:
In addition to the core driving palliative care
philosophy common to all the guidance, there
would be elements of technical guidance
specific to certain disease groups. They should
be designed to be readily adapted for local use
to meet the needs of individuals.
Increased uptake of Co-ordinate
my Care record (CMCR) for
patients discharged across the
Trust with life-limiting conditions
and accessing the disease
specific care plans for conditions
like: congenital heart disease,
MND, renal failure
Palliative care
EOLC CQUIN
lead
38. End of life care plan:
Use of the Liverpool Care Pathway should be
replaced within the next six to 12 months by an
end of life care plan for each patient, backed up
by condition-specific good practice guidance.
CHS to continue to use the LCP
for those patients who meet the
criteria and for whom this
decision has been made by their
consultant, and where their
consultant has discussed LCP
with their family, and where
family are in agreement
CUH palliative care team will
implement new EOLC
guidance in accordance with
guidance from Association of
Palliative Medicine and other
Palliative Care
Team
ADN for
Integrated
Care for CHS
CCG need to
agree course
of action for
those patients
outside this
remit
IMCA service
All staff
agencies. CUH will stop using
LCP within 12 months.
40. Hospital inspections:
End of life care should be incorporated urgently
into the hospital inspection programme of the
newly announced Chief Inspector of Hospitals.
CQC interviewed Palliative Care
Consultant and ward staff about
end of life care as part of their
visit 17-18.9.13
Executive
Board