title: Hospital doctors' understanding of use and withdrawal of the Liverpool Care Pathway: A qualitative study of practice-based experiences during times of change.
abstract: BACKGROUND
  The Liverpool Care Pathway was used in UK hospitals (late 1990s to July 2014) in an attempt to generate hospice-style high-quality end-of-life care in acute settings. Despite being widely established, there was limited research or contextual evidence regarding this approach or its impact. Growing criticism from the public, media, politicians and healthcare professionals culminated with a critical independent review (July 2013) and subsequent withdrawal of the Liverpool Care Pathway.
  
  
  OBJECTIVE
  This research explores experiences of doctors using the Liverpool Care Pathway, prior to and during its withdrawal, to better understand shortfallings and inform future initiatives in hospital end-of-life care.
  
  
  METHODS
  Individual semi-structured audio-recorded interviews were transcribed verbatim and concurrently analysed using thematic analysis.
  
  
  METHODS
  Following ethical approval, volunteer participants from an acute UK hospital were sought ( n = 73). A total of 18 specialist doctors were purposively selected.
  
  
  RESULTS
  Seven themes shaped doctors' experiences of using the Liverpool Care Pathway: (1) changing perceptions according to length of clinical practice, (2) individual interpretation and application of the Liverpool Care Pathway, (3) limitations arising from setting, speciality and basic end-of-life care competence, (4) understanding and acceptance of medical uncertainty at the end-of-life, (5) centrality of communication and fear of discussing dying, (6) external challenges, including a culture to cure, role modelling and the media and (7) desire for reassurance in end-of-life care decisions.
  
  
  CONCLUSIONS
  Future initiatives in hospital end-of-life care must address doctors' fears, (in)abilty to tolerate medical uncertainty, communication skills and understanding of the dying phase, in order to provide optimum care in the last days of life.
authors.affiliation: 1 West Midlands Deanery, Birmingham, UK.|2 Cardiff University, Cardiff, UK.
authors.forename: Sharon
authors.initials: S
authors.lastname: Twigger
authors.affiliation: 3 Central and North West London NHS Foundation Trust, London, UK.|4 University College London, London, UK.|5 Keele University Medical School, Keele, UK.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Yardley
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D005260:Female; D017051:Hospice Care / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000523:psychology* / Q000592:standards; D010820:Physicians / Q000523:psychology*; D036301:Qualitative Research; D013727:Terminal Care / Q000523:psychology* / Q000592:standards; D006113:United Kingdom
keywords: Health personnel; palliative care; qualitative research; terminal care; ‘Liverpool Care Pathway’