Liverpool Care Pathway

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Liverpool Care Pathway

• Lyn Dawkins

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• Care for the dying is urgent care with only one
  opportunity to get it right and to create a
  potential lasting memory for relatives and
  carers.

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What is a pathway?

• Determines locally agreed multidisciplinary
  practice based on guidelines and evidence where
  available for a specific patient / client group.
• It forms all or part of the clinical record
  replaces all other medical / nursing
  documentation and facilitates audit.

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Background

• NHS Cancer Plan (2000)
• Building on the Best (2003)
• NHS End of Life Programme (2004 2007)
• National Service Frameworks
• NICE Improving Supportive and Palliative Care for
  Adults (2004)
• National Audit Care of the Dying -
  Hospitals 2006 / 7
• Our Health Our Care and Our Say (2007)
• End of Life Care Strategy (2008)

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End of Life Care Strategy 2008

• Some people receive excellent care but the
  reality is that many patients do not.
• Many people experience unnecessary pain and other
  symptoms.
• Choice of place of death.
• Strategy built on Hospice care, NHS End of Life
  Programme, Delivering Choice and innovative
  practice.

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Last Days of Life Care Pathway

• Developed to transfer the Hospice model of care
  to other settings.
• Multi-professional document which provides an
  evidence based framework for end -of - life and
  after death care.
• Intended for the last few days of life.
• Incorporates guidance on anticipatory prescribing
  for GPs.

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Nationally

• 4 General Versions - not just for the cancer
  patient.
• Sub - specialist areas
• Intensive Care available, need to register
• Renal Failure - awaiting renal lead
• Heart Failure - awaiting report
• Paediatrics pilot / awaiting lead
• Future plans - Neurological and Dementia.

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Locally - Versions

• Hospital
• Hospice
• Care Homes Adapted from National
  version
• Community
• Commonalties exception of after death care.
• Specialist expertise and general challenge meet
  here in the dimension of our common humanity.

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Locally

• Change of name of Pathway.
• All versions currently have been reviewed
  updated.
• Awaiting ratification by Governance Assurance.
• Additions include
• triggers to support decision making.
• more extensive prescribing guidelines
• an opiate conversion chart.
• algorithms.

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Recognising Dying

• Decision to start the LCP requires the skilled
  practitioner to recognise and react appropriately
  to often subtle changes in the condition of the
  patient.

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Triggers decision making process

• Bed bound.
• Only able to take sips of fluids.
• Semi comatose.
• No longer to take tablets.
• Diagnosing dying is not always easy!

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Criteria

• All possible reversible causes for current
  condition have been considered and the
  multi-professional team has agreed that the
  patient is dying.
• There is a shortened life prognosis and may be a
  decreased level of consciousness.
• The patient is not for Cardio Pulmonary
  Resuscitation.

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Some Key Points - Family

• Discuss limited prognosis with relatives and if
  possible with the patient.
• If recovery is uncertain it is better to discuss
  this rather than give false hope.
• Emphasise that does not mean that you are giving
  up but rather that emphasis must be on quality
  rather than quantity of life. Try and turn it
  into a positive of what can be done.
• Discuss goal of future treatment to keep
  comfortable.

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Medical Section

• Discontinue non essential drugs.
• Prescribe PRN medication as listed on Pathway - 4
  core groups of drugs.
• Avoid inappropriate investigations.
• Ensure not for CPR is documented.
• Ensure Out of Hours Triage Bypass Card is
  completed community and care homes
  inappropriate resuscitation attempt.

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LCP discrete sections

• Initial assessment.
• Comfort measures.
• Variances useful audit tool.
• MDT page.
• After death care use this page for all deaths.

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After Death Care Audit

• Complete Page.
• Detach back page, complete and fax to GP.
• Use after death care for those patients that die
  but are not on the pathway.
• Audit - base line and pilot .
• After notify me please.

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Appropriate use of LCP

• Regular assessment.
• Continuous reflection.
• Critical decision making.
• Clinical skill.

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Critique of LCP

• Hospital - Offers a focus and relevant template
  of care. Increases confidence and empowerment for
  generic staff.
• Hospice - Aide memoir, consistency of care and
  useful for training staff new to the environment.
• Care Homes Gaynor.

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Critique of LCP

• Tick box exercise.
• Standardising patient care less individualised.
  However, vast inconsistencies in end of life care
  support the requirement for standardisation.
  Variances when used correctly facilitates
  individualised care.

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Critique of LCP

• Fear of making a mistake - not a one way ticket.
• Euthanasia
• LCP is the UKs main clinical pathway of
  continuous deep sedation (Treloar 2008).

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Advantages

• Wins time.
• Measurable, explicit and visible.
• Positive impact - change in culture.

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Education LCP

• Use of the Pathway and educational initiatives
  alone may not be sufficient to develop practice
  in relation to end of life care. Facilitating
  practice based guidelines such as the Liverpool
  Care Pathway alongside this education may
  reinforce practice development and confidence.

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Care Homes

• 33 Care Homes.
• Matron / managers .
• In home training.
• Two day course.
• Follow up focus group impact on practice.

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References

• Treloar, A. (2008) Continuous deep sedation
  Dutch research reflects problems with the
  Liverpool Care Pathway.
• Ellershaw, J. Wilkinson, S. ( 2003) Care of the
  dying . A pathway to excellence.