The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England.

Background : The Liverpool Care Pathway for the Dying Patient ('the LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review.  The ensuing debate among clinicians polarised between 'blaming' of the LCP and regret at its removal. Employing the concept of 'boundary objects', we aimed to address three 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. Results : The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP 'scandal' demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. 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. This was beyond its original remit. 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.