Friday, 15 March 2013

Liverpool Care Pathway - "The Pathway Is Here To Stay"

Bridget Johnston is an esteemed member of the Editorial Board of The International Journal of Palliative Nursing. It is Bridget Johnson, of course, who is behind the DCP (Dignity Care Pathway) which uses a PDI (Patient Dignity Inventory) to measure various sources of dignity-related distress among patients nearing the end of life. [The Patient Dignity Inventory: A Novel Way of Measuring Dignity-Related Distress in Palliative Care]

The DCP is quite some tool -
"Nurses identified that using the DCP allowed them to reconsider which patients required palliative care.  In line with Scottish Government (Scottish Government 2008) policy, this study encouraged nurses to consider approaching any patient who the nurse considered was in the last months of their illness, regardless of diagnosis, and including the frail elderly."
[PAGE 12 - QNIS Project Report]

The International Journal of Palliative Nursing recently published an article which pre-empts and circumvents any outcome of the current review into how the LCP (Liverpool Care Pathway) is put into practice.

'Old Pathways never die, they just change their name...'

Can the Liverpool Care Pathway 
make a recovery?
During the latter part of 2012, the Liverpool Care Pathway (LCP) came under some serious criticism in the media. Apparent examples of shocking bad practice were emphasised, including dying patients being deprived of food and water and in some cases not receiving any treatment at all, and a lack of communication with patients and families whereby they were unaware that the pathway had been implemented and/or no opportunity was presented for a patient to be taken off the pathway even if there was a marked improvement in their condition. These extremely serious allegations have the potential to cause concern and distress among existing patients’ families and potential patients alike. 

Undoubtedly, poor care has been provided in some instances. But what does this
mean for the health of the pathway itself? The LCP was developed in the late 1990s (Ellershaw and Wilkinson, 2010) by the Marie Curie Palliative Care Institute Liverpool as a framework for health professionals, to ensure that dying patients have as comfortable and dignified a death as possible. Its foundation is effective communication and discussions with all those concerned with the patient’s care. Facilitating such discussions around the end of life requires advanced communication skills and strategies that enable the professional to:

● Assess what the family already understands and how the LCP will affect them

● Respond to the different agendas and emotions that may be influencing family    
decision making, such as denial, guilt, anger, fear and sadness

● Establish needs and priorities

● Manage misperceptions and unrealistic or conflicting expectations and                   priorities

● Break bad news

Respond to loss and grief.

It appears from the media reports that not all of the organisations that implemented the LCP ensured that they had these staff skills and strategies in place, and yet most of them are essential for the care of dying patients regardless of whether a care pathway is being used. Hence, organisations that care for dying patients must now turn the media furore into positive action by examining their practices and making appropriate amendments. Organisations need to cascade their commitment to the principles of the pathway to all staff concerned. They must review how decisions are reached around identifying and managing patients who are entering the last few days of life. Reviews must also be undertaken to identify staff training and education needs, centred on diagnosing the dying, symptom control, and supporting families. These needs must then be prioritised, with investment in training where necessary. In addition, all professionals working in end-of-life care have a responsibility to themselves, their profession, and their patients to ensure that they have the required level of competence. They must be proactive in their self-assessment and in highlighting their training needs.

We must not allow the shortcomings reported by the media to deflect attention from the outstanding work that the majority of health professionals provide using the LCP. The independent review of the LCP being chaired by Baroness Julia Neuberger has been welcomed by the Marie Curie Palliative Care Institute, which looks forward to her forthcoming findings. Ultimately, these can only help to improve the current image of the pathway and restore the public’s trust in the professionals caring for the dying. The name of the pathway may change, but its principles are here to stay.
Carole Mula

Macmillan Nurse Consultant in Palliative Care, The Christe NHS Foundation Trust, 

Ellershaw J, Wilkinson S (2011) Care of the Dying. A Pathway to Excellence. 2nd edn. Oxford 
University Press

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