The Liverpool Care Pathway - who decides?

Jeremy Paxman conducted a lively discussion yesterday on Newsnight about the so-called Liverpool Care Pathway. The care pathway has drawn some criticism from patients and carers after it has become clear that it is essentially a way to design a dignified death for patients. While this is laudable where patients are terminally ill, critics argue that it is not clear when and under which circumstances the care pathway should be implemented in individual cases, leaving it open to be used as a 'smokescreen for euthanasia'. 

The care pathway has originally been developed by palliative care professionals and geriatricians in Liverpool, but it is now widely applied in NHS hospitals. The interesting conflict however is not so much one about when to apply it but one about who makes the decision to do so. 

Newsnight showed a brief interview with a relative of a patient who was put on the care pathway. In essence, the relative argued this was a decision to let the patient die without exploring alternative routes to address the illness of patient. She reportedly 'begged the consultant' to save the life of the patient instead of applying the Liverpool Care Pathway. In such situations, the Liverpool Care Pathway may resemble more a professional device to conceal clinical decisions from relatives and patients, rather than  an instrument for delivering exemplary palliative care. 

The discussion amongst Paxman's guests however moved quickly away from the critical point that was made by the relative of the patient (and another guest in the studio) towards the 'soft' issue of how to involve patients or relatives in the discussion about the care pathway. This however dodged the actual problem of clinical decision making. 

As one of the guests emphasised, the question is about WHO makes the decision. Relatives often do not just want to be consulted in the difficult cases but want to make the decision itself. So, in difficult cases, consultation is not enough. The Minister for Care Services Norman Lamb waffled for a while and managed to skirt around the real issue, but anybody who listened carefully couldn't have been in any doubt. As medical knowledge is more widely disseminated in the population, patients and relatives will increasingly challenge clinicians in their decision making and 'consulting' is taken to be synonymous with 'deciding'. No one in the studio pointed out that consultation in the clinical context does NOT mean a fundamental shift of the decision making authority from clinical staff to relatives or patients. 

The relative brought this to the point when he said that it should be the family or the patient who decides which services he or she receives. We may agree or disagree with this, but the main message is clear. The times when NHS clinicians could make decisions on their own is over. Nowhere is this more clear then in deciding who lives or dies.