Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the 'boundary object' concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
Highlights
Major policy innovations covering a whole jurisdiction are rare in palliative care
Following Carlile’s28 description of boundary object implementation as a process involving transfer, translation and transformation, we have shown how the LCP quickly assumed national prominence as a key means to deliver the goals of a National End of Life Care Strategy[10]
The available provision of palliative care through hospices and specialist palliative care units in hospitals was clearly incommensurate with the prevailing level of need for such services and the number of people who could beneit from them
Summary
Major policy innovations covering a whole jurisdiction are rare in palliative care. When one such intervention is introduced with government support and with a vigorous programme of implementation, but runs into signiicant dificulties, it is vital to make sense of the factors at work. The Liverpool Care Pathway for the Dying Patient (LCP) was an intervention based on an integrated care pathway It grew out of the hospice context and over more than a decade was promoted across the health care system in the United Kingdom before it was suddenly withdrawn from use. Integrated care pathways Integrated care pathways (Box 1) are complex interventions to enable the organization of health care for speciic groups of patients, often in the context of time limited decision-making[14]. Their use commonly involves structured documents outlining essential steps in care to be followed by members of multidisciplinary teams involved with particular groups of patients.
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