POST PATHWAY FEEDBACK

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Forest Holme Hospice

• POST PATHWAY FEEDBACK

September 2006 January 2007
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Background

• The modern hospice movement was established in
  response to the poor quality of care of the dying
  patient
• The hospice model of care is now generally
  regarded as the gold standard for the dying
  patient
• A major challenge is to transfer best practice
  from a hospice setting to other care settings
• The Liverpool Care Pathway (LCP) for the Dying
  Patient is a multi-professional document that
  provides a template for client centred best
  practice and facilitates appropriate standards of
  record keeping (see Essence of Care, DOH, 2003)

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Background

• The development of the LCP has led to measurable
  outcomes of care
• The LCP was awarded Beacon Status in September
  2000 to facilitate the process of dissemination
  of good practice
• More than 300 centres across the UK are involved
  in work related to the pathway

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3 Sections of the LCP

• Initial assessment and care
• Ongoing assessment and care
• Care after death

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Goals of care for patients encompassed by the LCP

• Physical
• Psychological
• Religious / Spiritual
• Social

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Forest Holme Hospice
POST PATHWAY FEEDBACK RESULTS
September 2006 January 2007
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Demographics (n20)
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Demographics (n20)
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SECTION 1
Initial Assessment and Care
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Comfort Measures

• Goal 1 Current medication assessed and
  non- essentials discontinued
• Goal 2 As required subcutaneous drugs written
  up according to protocol 2.1 Pain
• 2.2 Nausea vomiting
• 2.3 Agitation
• 2.4 Respiratory tract secretions
• 2.5 Dyspnoea

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Comfort Measures (n20)
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Comfort Measures

• Goal 3 Discontinue inappropriate interventions
• 3.1 Blood tests
• 3.2 Antibiotics
• 3.3 IV Fluids
• 3.4 Not for CPR
• 3.5 Deactivate cardiac defibrillators (ICDs)
• Goal 3a Discontinue inappropriate nursing
  interventions
• Goal 3b Syringe Driver set up within 4 hours
  of Doctors order

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Comfort Measures (n20)
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Psychological / Insight Religious/Spiritual

• Goal 4 Ability to communicate in English assessed
  as adequate
• 4.1 Patient
• 4.2 Family/ Other
• Goal 5 Insight into condition assessed
• Aware of Diagnosis
• 5a1 Patient
• 5a2 Family/other
• Recognition of Dying
• 5b1 Patient
• 5b2 Family/other

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Psychological / Insight Religious/Spiritual

• Goal 6 Religious / spiritual needs assessed
  6.1 Patient
• 6.2 Family/other

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Psychological/Insight Religious needs (n20)
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Communication

• Goal 7 How family/other to be
  informed of patients impending death
• Goal 8 Family/other given
  hospital/hospice information leaflets
  (Accommodation, car parking, dining room
  facilities etc)
• Goal 9 General Practitioner is aware of
  patients condition
• Goal 10 Plan of care explained to
• 10.1 Patient
• 10.2 Family/other
• Goal 11 Family/other understanding of plan of
  care

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Communication (n20)
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Impact of LCP on practice at Forest Holme

• Attempting to achieve these goals has focused on
  the need to maximise family/carer understanding
  of the dying process.
• Introduction of the Coping with Dying leaflet
  has been a very helpful supportive tool for
  families.
• This leaflet was devised to meet a need
  identified by nurses when the LCP was first
  developed in Marie Curie Hospice in Liverpool
• Potentially valuable on most wards in Poole
  Hospital

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SECTION 2

• Assessment and Ongoing Care

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Assessment of Ongoing Care

• Pain, agitation, respiratory tract secretions,
  nausea and vomiting, dyspnoea, mouth care,
  micturition, medication
• Mobility / pressure area care, bowels assessed,
  psychiatric insight of patient / carer, religious
  support, care of the family

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Assessment of documentation of ongoing care (4
hourly)
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Assessment of Ongoing Care (12 hourly)
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Number of Variances per patient (n20)
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SECTION 3

• Care After Death

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Care After Death

• Goal 12 GP Practice contacted re patients death
  date
• Goal 13 Procedure for laying out followed
• Goal 14 Procedure following death discussed or
  carried out
• Goal 15 Family/ other given information on
  procedures
• Goal 16 Hospital Policy followed for patients
  valuables belongings
• Goal 17 Necessary documentation and advice is
  given to the appropriate person
• Goal 18 Bereavement leaflet given

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Care after Death (n20)
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What do we do well?

• Start LCP at correct time in most cases (Average
  time on LCP 32 hrs)
• Achieve rationalisation of meds prn meds in 98
• Stop unnecessary interventions set up S/D in
  70
• Excellent documentation of family aware, contact
  details hospice info in 90
• Documentation of 4hrly ongoing care in 84
• Excellent emotional support to pt. family in
  88

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Could do better ?

• 30 missing documentation of DNR status
• Religious/spiritual needs only documented in 25
  of patients 50 of families
• GP only made aware in 25
• Bowel care not documented in 31
• On average only document 64 of care after death

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Issues around uptake of LCP at FRHM

• Total No. deaths in 5 mths 59
• No. onto LCP 26
• Only 44 on LCP (viz 85 uptake in
  Liverpool hospice)
• WHY?

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Demographics of two patient groups (n20)
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Demographics of two patient groups (n20)
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Possible contributing factors to LCP not being
started in 56 of cases

• Average age in non LCP group 10yrs younger
• Shorter length of time in FRHM til death (one
  week compared to two)
• Predominance of GIT tumours??
• (management of obstructive symptoms in 18
  with therapeutic manipulation which may distract
  from objective clinical overview)
• Inevitable risk of sudden death in cancer illness
  ?magnified in hospice cohort (in fact 12
  recorded as sudden/unexpected in this study)

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Conclusions Poole Hospital Specialist
Palliative Care Unit 2007

• Taking time to adopt ethos of the LCP
• Is improving because team realise need to be more
  accountable through adequate documentation
• LCP already proving to be a powerful audit tool
• Only then can standardisation to optimum care of
  the dying eventually be achieved and maintained,
  regardless of where people die