Select Committee on Health Written Evidence


Memorandum by Dr John Ellershaw and Deborah Murphy (PC 29)


  As National Clinical Leads in Palliative Care for the Cancer Services Collaborative we welcome the opportunity to contribute evidence to the inquiry. One of our main aims is to empower health care professionals in care for the dying by implementing the Liverpool Care Pathway for the Dying Patient (LCP). The pathway has been used to care for patients with cancer and other life limiting diseases in all care settings.

  1.1  Too often, patients' last weeks, days and hours of life are spent in avoidable pain, discomfort and confusion, causing additional unnecessary distress and trauma to carers, loved ones and all others affected by imminent death—including healthcare staff often struggling to do their best in difficult circumstances.

  1.2  The LCP empowers doctors and nurses to deliver high quality care to dying patients and their relatives. It facilitates multiprofessional communication and documentation, integrating national guidelines into clinical practice. The project promotes the education and empowerment role of the Specialist Palliative Care Team to bridge the theory practice gap. It provides demonstrable outcomes to support clinical governance and should reduce and inform complaints commonly associated with this area of care. The LCP was awarded National Beacon Status in the category Palliative Care in September 2000.

  1.3  The aim of the LCP Project is to translate best practice for care of the dying from the hospice into the acute sector and develop outcome measures at the end of life. The aim now is to build on the existing Beacon Dissemination Programme and co-ordinate a national model of spread and sustainability of the LCP across the 34 NHS Networks linked with the CSCIP and supported by Marie Curie Cancer Care.

  1.4  The LCP project will achieve its outcomes through a national infrastructure implementing an educational and evaluation spread model that will enable the uptake of the LCP within a collaborative approach that translates into the mainstream. The key methodology adopted by the national infrastructure will be based on a robust Ten Step Implementation Programme and a Research and Evaluation Model. This supports clinically based educational programmes, sustained interest in the clinical workforce and attention to cultural organisational changes to ensure achievement of objectives and outcomes.

2.  The Liverpool Care Pathway Project is applicable to a number of points within the Terms of Reference of the Enquiry.

  2.1  Issues of choice in the provision, location and timeliness of palliative care services, including support to people in their own homes

  The implementation of the LCP involves an education programme by specialists in palliative care to empower generalists to deliver high quality care to dying patients. This empowerment of generic workers enables patients to be recognised as in the dying phase and treated with dignity in their own homes.

  2.2  Equity in distribution of provision both geographical and between different age groups

The LCP provides a framework of care that is appropriate for all age groups and although initially developed for cancer patients has been used in a wide range of disease types including renal failure, chronic obstructive airways disease and cardiac failure. Frameworks are currently being developed for Intensive Care Units and Paediatric Services.

  2.3  Communication between clinicians and patients; the balance between people's wishes and those of carers, families and friends' the extent to which service provision meets the needs of different cultures and beliefs.

  The Liverpool Care Pathway identifies the key areas of care for dying patients, including the physical care with associated guidelines for pain control, agitation, respiratory tract secretions and nausea and vomiting.

  Psychological issues relevant to the patient and social support of the family are also identified. Importantly communication with the family that the patient is dying is a key area identified in the LCP. Issues of language/translation and respecting and meeting the needs of different cultures and beliefs is also incorporated within the framework.

  2.4  Quality of service and quality assurance

  The LCP provides ongoing recording of care which can then be audited and analysed. We are currently working on a benchmarking pilot project within the Merseyside and North Cheshire Cancer Network and are also in discussion with the Royal College of Physician Outcomes Unit regarding a National Project in this area. Benchmarking care of the dying is an important step forward in quality assurance and the clinical governance agenda.

  2.5  Governance of charitable providers, standards of organisation, links to the NHS and specialist services

  The LCP framework incorporates evidence based care and national guidance into everyday practice. It also highlights areas of care that have not been carried out as well as acting as benchmarking tool. It therefore links directly with issues of clinical governance. Following the education programme the LCP framework helps guide practice for generic health care workers who can then access specialist support if required. It has been implemented not only in the NHS, but also within the voluntary sector in hospices and nursing homes.

  2.6  Workforce issues including the supply and retention of staff and the quality and adequacy of training programmes.

  The Liverpool Care Pathway Framework has been incorporated into training programmes for care of the dying and leads to a framework of care that generic health care workers can then deliver to dying patients. It promotes the education and empowerment role of the Specialist Palliative Care Team.

  2.7  The impact and effectiveness of Government policy including the National Service Frameworks, the Cancer Plan and NICE recommendations.

  Care of the Dying was highlighted in the Cancer Plan with regard to improvement of the care of the dying to the level of the best. It has also been highlighted in a number of National Service Frameworks including Coronary Heart Disease and Older People.

Quotes from National Services Framework and Care of the Dying

  "Too many patients will experience distressing symptoms, poor nursing care, poor psychological and social support and inadequate communication from healthcare professionals during the final stages of an illness. This can have a lasting effect on carers and those close to the patient, who often carry the burden of care. The care of all dying patients must improve to the level of the best"

  "The NHS Cancer Plan—A plan for investment, A plan for reform" 2000;Department of Health Chapter 7,21:66

  "In stroke where recovery is not possible, this should be recognised by staff. The care of the patient should be discussed with them as far as possible and with their carers as appropriate. The principles of palliative care should inform the care plan, with priority being given to supporting the patient to die with dignity, without unnecessary suffering and in the place of their choice wherever possible".

  National Service Framework for Older People 2001; Department of Health, Chapter 5,5:23

  "When the underlying aim of treatment is to control symptoms, a palliative approach with help from palliative care specialists can improve a patient's quality of life."

  National Service Framework for Coronary Heart Disease 2000;Department of Health, Chapter 6,18


NICE Guidance for Supportive and Palliative Care

  The LCP Framework is incorporated within the new NICE Guidance for Supportive and Palliative Care both within the generalist palliative care section and as:

Key Recommendation 14:

  "In all locations, the particular needs of patients who are dying of cancer should be identified and addressed.

  The Liverpool Care Pathway for the Dying Patient provides one mechanism for achieving this."

3.  Recommendations for action

  3.1  The Liverpool Care Pathway has provided a framework to translate best practice of Care of the Dying in a hospice setting to other care settings. Adequate resources should be made available to disseminate the LCP framework throughout the country.

  3.2  It is important to sustain the LCP Project by benchmarking on a National basis care of the dying in all care settings.

  3.3  A unified approach and adequate resources from health and social care should be provided for patients who choose to be cared for in their own home or a nursing home rather than being admitted to an acute hospital to die.

  3.4  A key development which would promote best practice for care of the dying for all patients in all settings with all diseases would be the formation of an end of life collaborative/alliance. This could drive forward the national policy identified within this submission together with promoting other models of excellence of care of the dying and palliative care.


  1.  Ellershaw J E Wilkinson S Co-editor and Contributor "Care for the dying: A pathway to excellence". Oxford University Press, April 2003.

  2.  Ellershaw J E, Murphy D, Shea T, Foster A, Overill S "Development of a multiprofessional care pathway for the dying patient" European Journal of Palliative Care 1997;4(6):203-208.

  3.  Ellershaw J E, Ward C "Care of the dying patient: the last hours or days of life" BMJ 2003;326:30-4.

  4.  Ellershaw J E, Smith C, Overill S, Walker S E, Aldridge J "Care of the dying: Setting standards for symptom control in the last 48 hours of life" Journal of Pain and Symptom Management 2001; 21(1):12-17.


February 2004

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