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Liverpool Care Pathway end of life dying patients
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Here is a comprehensive overview of both the Liverpool Care Pathway (LCP) and liver-specific care pathways, covering their overlap and key clinical guidance.
Liverpool Care Pathway (LCP)
Background
The Liverpool Care Pathway was a UK-developed framework designed to standardise end-of-life care for dying patients in the last hours to days of life, modelled originally on hospice care. It was withdrawn from use in the UK in 2014 following the Neuberger Review (due to concerns over blanket application and inadequate communication with families), and replaced by NICE Guideline NG31: Care of Dying Adults in the Last Days of Life (2015).
The principles it embodied remain embedded in modern end-of-life care.
Core Principles of End-of-Life Care (LCP-derived framework)
1. Recognition of Dying
Identifying when a patient is in the last hours to days of life. Clinical signs include:
- Profound weakness and fatigue; bedbound
- Reduced/absent oral intake; dysphagia; loss of gag reflex
- Mottling, peripheral cyanosis, altered breathing (Cheyne-Stokes)
- Reduced/absent urine output
- Altered consciousness, agitation (terminal restlessness)
(Harrison's Principles of Internal Medicine, 21st Ed., p. 485)
2. Comfort-Focused Care
| Domain | Interventions |
|---|---|
| Pain | Anticipatory subcutaneous morphine; syringe driver if needed |
| Breathlessness | Low-dose opioids, positioning, fan therapy |
| Agitation/delirium | Midazolam, haloperidol, or levomepromazine |
| Respiratory secretions | Glycopyrronium or hyoscine butylbromide |
| Mouth care | Oral swabbing, lip lubricants, artificial tears (not forced feeding) |
| Pressure care | Balance repositioning comfort vs. pressure ulcer prevention |
3. Medication Review
- Discontinue non-essential medications (statins, antihypertensives, supplements)
- Convert oral medications to subcutaneous/syringe driver
- Prescribe anticipatory medications ("just in case" box)
4. Nutrition and Hydration
- Clinically assisted nutrition/hydration is generally not appropriate in the last days of life unless there is a specific reversible indication
- Patient/family communication is essential regarding this decision
5. Communication and Family Support
- Clear, compassionate explanation of the dying process to family
- Goals of care documented; advance care planning reviewed
- Spiritual/religious needs addressed
- After-death care planned
Liver Disease — Palliative & End-of-Life Care Pathway
When to Initiate Palliative Care in Liver Disease
Palliative care is underutilised in end-stage liver disease (ESLD) despite strong evidence of benefit:
- ~50% lower readmission rates in patients with cirrhosis receiving palliative care consultation
- Shorter length of stay
- ~$10,000 cost saving per patient with ESLD
- Readmissions cut by two-thirds; doubled chance of hospice discharge
- Palliative care consultation most often occurs too late in current practice
(Acute-on-Chronic Liver Failure and the Management of Critically Ill Patients with Cirrhosis, p. 30)
Triggers for Palliative Care Referral in Liver Disease
| Trigger | Detail |
|---|---|
| MELD score ≥ 15–20 | High 90-day mortality; consider early referral |
| Recurrent hepatic encephalopathy | Especially if not transplant candidate |
| Refractory ascites | Requiring frequent large-volume paracentesis |
| Hepatorenal syndrome | Type 1 (AKI) or Type 2 |
| Acute-on-chronic liver failure (ACLF) Grade 2–3 | Very high short-term mortality |
| Not a transplant candidate | No curative option; shift to comfort goals |
| Recurrent variceal bleeds | Especially without TIPS eligibility |
Specific Symptom Management in ESLD
| Symptom | Management |
|---|---|
| Pruritus | Cholestyramine, rifampicin, naltrexone, MARS |
| Ascites | Diuretics, large-volume paracentesis, TIPS; in terminal phase — comfort-focused drainage |
| Hepatic encephalopathy | Lactulose, rifaximin; in terminal phase — address as delirium/agitation |
| Pain | Use with caution — reduce opioid doses (impaired metabolism); prefer low-dose opioids titrated carefully |
| Fatigue | Energy conservation, multidisciplinary support |
| Malnutrition | Nutritional support (branched-chain amino acids); not appropriate to force in final days |
Advance Care Planning in Liver Disease
- Patients with cirrhosis prefer to undertake advance care planning before clinical deterioration — this should not be deferred until crisis
- Discuss: DNAR status, preferred place of death, organ donation (where relevant), transplant candidacy, and hospice goals
- Family/carer involvement is critical
NICE NG31 (2015) — Replacing the LCP in the UK
Key recommendations:
- Individualise all decisions — no blanket application
- Maintain hydration where appropriate and desired
- Review the dying diagnosis at least every 24 hours
- Communicate prognosis and care plan clearly with patient (if capacity) and family
- Prescribe anticipatory medications for the five key symptoms (pain, breathlessness, agitation, secretions, nausea)
In summary: The Liverpool Care Pathway was replaced by more individualised frameworks (NICE NG31), but its core principles guide end-of-life care today. In liver disease specifically, early palliative care integration — rather than late-stage referral — significantly improves patient outcomes, reduces hospital burden, and aligns care with patient preferences.
liver pool care pathway orthopaedics
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hip fracture care pathway elderly dying end of life orthopaedic
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end of life care pathway dying orthopaedic ward hospital
The Liverpool Care Pathway (LCP) in an orthopaedic context most commonly arises in two scenarios: dying patients on orthopaedic wards (particularly after hip fracture in elderly patients) and the intersection with perioperative decision-making. Here is a focused overview.
Liverpool Care Pathway in Orthopaedics
Context
Orthopaedic wards — particularly hip fracture units — frequently care for elderly, frail patients who may deteriorate and die during admission. The LCP was historically applied on these wards, and its successor frameworks (primarily NICE NG31: Care of Dying Adults in the Last Days of Life, 2015) now guide practice.
Hip Fracture: The Key Orthopaedic End-of-Life Scenario
Epidemiology
- ~75,000 hip fractures per year in the UK
- 30-day mortality: ~8–10%; 1-year mortality: ~30%
- Many patients are elderly with multiple comorbidities — a significant proportion will die on the orthopaedic ward
When to Consider End-of-Life Pathway on an Orthopaedic Ward
| Trigger | Detail |
|---|---|
| Failure to recover post-operatively | Persistent deterioration despite surgery |
| Pre-operative frailty + acute deterioration | Patient unfit for surgery, declining despite conservative care |
| Multi-organ failure / sepsis | Post-operative complication with no reversible cause |
| Patient or family's expressed wishes | Preference for comfort-focused care |
| Clinical signs of dying | Bedbound, not eating/drinking, altered consciousness, mottling |
Applying the End-of-Life Framework (Post-LCP) in Orthopaedics
1. Recognition of Dying
The MDT (surgeon, orthogeriatrician, nurse) should identify when a patient is in the last hours to days of life. This requires:
- Senior clinical review
- Reversible causes excluded (e.g. treatable infection, PE, delirium)
- Documentation of the dying diagnosis, reviewed every 24 hours
2. Goals of Care & Communication
- DNAR (DNACPR) discussion — should occur early in high-risk admissions, not just at point of crisis
- Preferred place of death
- Family/carer meeting — clear explanation that the patient is dying
- Spiritual/cultural/religious needs addressed
3. Medication Management
| Symptom | Drug | Route |
|---|---|---|
| Pain | Morphine 2.5–5 mg | SC PRN / syringe driver |
| Agitation / terminal restlessness | Midazolam 2.5–5 mg | SC PRN |
| Respiratory secretions | Glycopyrronium 200 mcg | SC PRN |
| Nausea | Haloperidol 0.5–1 mg | SC PRN |
| Breathlessness | Low-dose morphine | SC PRN |
- Prescribe anticipatory medications proactively ("just in case" box)
- Convert to syringe driver if ≥2 PRN doses needed in 24 hours
- Discontinue non-essential medications (anticoagulants, antihypertensives, bisphosphonates, statins)
4. Nutrition & Hydration
- Clinically assisted hydration: consider if patient distressed by thirst or if death not imminent — individualise, do not blanket withdraw
- Mouth care: oral swabbing, lip lubricants — continue throughout
5. Wound & Surgical Care
- Continue wound care for comfort (prevent distressing exudate/odour)
- Surgical drain removal if causing discomfort and no clinical benefit
- Pressure care: reposition for comfort; mattress upgrade if available
6. Nursing & Environment
- Single room if possible
- Flexible visiting for family
- Explanation of dying process (mottling, breathing changes, reduced consciousness) to prepare family
Perioperative Decision-Making: Surgery at End of Life
For patients on an end-of-life pathway who sustain a hip fracture, or where surgery is being considered in a patient who is clearly dying:
| Scenario | Approach |
|---|---|
| Patient actively dying | Surgery not appropriate; prioritise comfort |
| Frail patient, uncertain prognosis | Orthogeriatric assessment; shared decision with patient/family; risks vs. benefit of surgery for pain control |
| Surgery for pain control only (e.g. internal fixation) | May be appropriate even in palliative context — "anaesthetic palliation" |
| Patient with DNAR in place | DNAR does NOT preclude surgery; document peri-operative DNAR status clearly |
Key principle: A DNAR order applies only to cardiopulmonary resuscitation. It does not mean "do not treat" — surgery, anaesthesia, and active pain management remain appropriate where they serve the patient's comfort goals.
Orthogeriatrics & Collaborative Care
Best practice in hip fracture care involves orthogeriatric co-management, which integrates:
- Frailty assessment (Clinical Frailty Scale)
- Advance care planning early in admission
- Proactive palliative care referral for high-risk patients
- Liaison with community/hospice for discharge planning
Summary
| Aspect | Key Point |
|---|---|
| LCP replaced by | NICE NG31 (2015) — individualised approach |
| Commonest orthopaedic scenario | Elderly hip fracture patient deteriorating post-op |
| Core actions | Recognise dying, anticipatory medications, DNAR, family communication |
| Surgical context | Surgery for pain relief can still be appropriate in palliative patients |
| DNAR & surgery | DNAR ≠ do not treat; document peri-operative DNAR explicitly |
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