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Palliative care pharmacist defends Liverpool Care Pathway for dying patients

An expert palliative care pharmacist has come out in defence of the Liverpool Care Pathway at the Clinical Pharmacy Congress, which took place last week in London (26 April 2014).

Ray Bunn, community and specialist palliative care pharmacist, Kamsons pharmacy and St Catherine’s Hospice, Crawley, told participants: “Despite adverse publicity in the national press, I firmly and passionately believe that this particular protocol is a good thing. I am sure in some situations it may have been misused or the way it has been used may have been misinterpreted but I think generally it is an excellent tool.”  He told The Pharmaceutical Journal that the Liverpool Care Pathway (LCP) for the dying patient and its local adaptations empower the multi-professional team to deliver high-quality care to dying patients and their relatives.

A review of the LCP was published in July 2013 following reports of it being used to over-administer strong painkillers or to withhold fluids.

Recommendations from the review said that the pathway should be phased out over six to 12 months and replaced with individual care plans.

Mr Bunn told The Journal that the pathway is not being scrapped, but more revised and reviewed. “National lead palliative care organisations are reviewing the LCP with a view to making improvements. One message coming out of the review groups is that the revised pathway will be adapted to more of a plan and named as such,” said Mr Bunn, explaining that it will probably be called the Liverpool Care Plan. 

Mr Bunn said that the original pathway had been developed as a tool for a high-quality, standard best-practice approach to care in the last few days or hours of life. “A key purpose of the LCP was to translate specialist hospice care practice into the acute and primary care sectors, including initial assessment and ongoing care of the dying patient and care of the family and relatives after the death of the patient,” he told The Journal.

He stressed that whether or not patients are entering the dying phase is a multi-professional decision and the LCP flags up the care interventions that can be considered in the terminal phase, as well as psychological, social and spiritual support for the patient and family. “It ensures that everything that needs to be addressed is addressed,” he said, adding that “before the LCP there was no guidance”.

Mr Bunn also discussed the medicines available to treat the common symptoms experienced by patients at the end of their life. For pain, he told conference participants that there is now rarely any need for the use of diamorphine. He explained to The Journal: “The only specific indication in clinical practice where diamorphine might be the strong opioid of choice is where a very high dose of analgesic is needed in a low volume of diluent due to its high solubility. However, in my experience of clinical practice locally this is very rare indeed.” He recommended that national formularies take these factors into consideration and should be “clear” that diamorphine’s use has no other advantages and that it is expensive.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11138022

Readers' comments (1)

  • I think that the last paragraph just needs a bit of clarification, and I am sure Ray mentioned this.  Diamorphine should only be reserved for patients requiring high doses, so "there is now rarely any need for the use of diamorphine." Patients, however, will still need an opioid to manage pain at the end of life. 

    A recent national survey undertaken by Marie Curie/CRUK has determined that the most commonly prescribed opioid for administration via a continuous subcutaneous infusion is morphine.

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