Dutch research reflects problems with the Liverpool care pathway

The Liverpool care pathway (LCP) is the UK’s main clinical pathway of continuous deep sedation and is promoted for roll out across the NHS.¹ Rietjens et al’s study highlights some serious weaknesses in its design.²

The eligibility criteria do not ensure that only people who are about to die are allowed on to the pathway. They allow people who are thought to be dying, are bed bound, and are unable to take tablets on to the pathway. In chronic diseases such as dementia, dying can take years, but such patients may be eligible. Reitjens et al’s paper shows that GPs often put patients on to such a pathway without palliative care advice. A pathway for general use should minimise opportunities for early or inappropriate use.

Murray et al are concerned that sedation is being used as an inexpensive alternative to assessment and specialist treatment.³ The LCP recommends sedatives and opiates for all patients on an “as required” basis, even when they are not agitated, in pain, or distressed. An automatic pathway towards prescribing heavy sedatives incurs risks.

Moreover, the LCP recommends setting up a syringe driver within four hours of a doctor’s order. This is laudable, if it is needed. But the pathway encourages the use of syringe drivers even when symptoms can be managed without them.

The pathway doesn’t mention the need for food and fluids. Reitjens et al show that withholding artificial nutrition and hydration is the norm. The LCP’s omission of prompts to reconsider nutrition and hydration may allow serious errors in the care of dying patients. It is not acceptable, as Murray et al suggest, that assessing nutrition and hydration are not part of the pathway.

Sedation is right in some situations. But as Murray et al point out, the anticipated outcome of continuous deep sedation is death. We must learn from Reitjens et al’s observation that continuous deep sedation may replace euthanasia. If the methods and pathways that we use for continuous deep sedation in the UK are flawed, then patients will die as a result of inappropriate use. I hope that the LCP will be reviewed and modified.