Update

NICE have just released their updated guidelines on lipid modification for both primary and secondary care.  These have led to a lot of debate about the pros and cons of reducing the threshold for starting statins in patients with a cardiovascular risk of 20% to 10%.  It may also have ramifications in terms of workload for general practice in terms of monitoring statin use.

 

Health Education England have also just released their report on how to shore up the falling numbers of GPs.  The report focuses on the shift of hospital training jobs to general practice, although how this work when current GP training vacancies are underfilled is yet to be seen.

 

Finally, there was an excellent Radio 4 programme on assisted dying. There is currently a bill going through the House of Lords and the debate on Radio 4 is very thought provoking, especially as caring for dying patients forms such an important part of a GP’s daily work.

 

The Liverpool Care Pathway: Independent Review

The Department of Health has now published the report on the Liverpool Care Pathway.  Both the RCGP and the BMA have released their initial responses.

 

Parts that stood out for me included:

 

“Clinicians should be required to demonstrate proficiency in caring for the dying, doctors as part of each five-year cycle of revalidation” (p.10)

 

“significant lack of clarity over the meaning of the term ‘end of life.’ Variously, ‘end of life’ covers the last year of life of a person with a chronic and progressive disease, the last months, the last weeks or – for the LCP – the last hours or days of life: in short, the dying process” (p.13)

 

“the GMC’s guidance makes clear, as a matter of good practice and respect, the clinician should explain their thinking, ensure it is understood, and offer referral for another opinion if appropriate. This is the proper process of joint decision-making.” (p.25)

 

“There can be no clinical justification for denying a drink to a dying patient who wants one, unless doing so would cause them distress” (p.28)

 

“During the relatives’ and carers’ sessions held by the Review, numerous people recounted that agreement not to attempt cardiopulmonary resuscitation had been taken by the clinical staff as a proxy for agreement to start the LCP. This is completely inappropriate” (p.32)

 

“a named consultant or GP should respectively take overall responsibility for the care of patients who are dying in hospital or the community” (p.37)

 

It will be interesting to see where we go next from here and whether or not care for dying patients will improve.  As a training scheme we will need to reflect on our approach to helping GP trainees learn about the management of dying patients.  Some thought provoking blogs from other doctors in the NHS can be found here: Dr Phil Berry “An Opaque Code: the Liverpool Care Pathway and a gap in perception”, Dr Claire Dow “Musings on the LCP” and Dr Elin Roddy “End of Life Care in hospital – a twitter conversation”.

 

Further resources on the LCP can be found here.

 

End of Life Care: The Liverpool Care Pathway

The Liverpool Care Pathway (LCP) has come under increasing scrutiny in recent months.  Originally created as “a model of care which enables healthcare professionals to focus on care in the last hours or days of life when a death is expected.” (The National End of Life Care Programme) the LCP has been criticized in some sections of the press, who have led with emotive headlines.

 

Even within the medical profession there are conflicting opinions.  In one survey 90 % of doctors said that they would want to be placed on the LCP if they had a terminal illness.  However other voices within the profession have raised concerns about patients being placed on the LCP who may have a chance of recovering.

 

Amidst these conflicting points of view a different approach has been taken by Guy’s and St Thomas’ NHS Foundation Trust.  They have produced a tool known as the AMBER care bundle©, which aims to provide “greater clarity around preferences, and plans about how these can be met”.  It would appear that this tool takes into account (to a greater degree than the LCP) the uncertainty that surrounds the accurate identification of patients who are dying and allows for a more flexible management plan.

 

With an independent review of the LCP currently being undertaken by the Department of Health there is likely to be further scrutiny and debate.  As GP Trainees you will be caring for patients, and their relatives, who require end of life care and who will have their own views and thoughts about tools such as the LCP.  It is important that you are able to recognise how patients’ concerns may be shaped by personal, local and national factors.

 

Further resources can be found here: RCGP, The Marie Curie Palliative Care Institute and and the BMJ (care of the dying patient in the community and hospital).  Local information: National End of Life Care Profile for Barnsley PCT (2012) and Barnsley Hospice.