Liverpool Care Pathway - Another Slippery Slope

Is it easier to pick them off for EoLC than to pick them out for rehab?




 

A&E is "overstretched". Bringing them back from the brink is a costly affair. And is it worth it?

Are they worth it? Their life-style is self-destructive. They're slowly killing themselves.

It's another slippery slope. To downsize care is to downsize worth.

This is Druglink –

Turn to page 20...

How do you foster and set in place a culture of futility, of seeing the glass half empty?

Downsizing care expectations –

Death and dying along with birth and taxes are the certainties of this world – so why is it so difficult to either begin the dialogue or pick up and run with the cues; ‘I’ve not got long for this world’ can so often be met with ‘Don’t be daft, you’ll be around forever!’

Highly skilled EOL education facilitators provided the much needed confidence and common sense approach to having ‘the conversation’, helping to alleviate concerns around saying the wrong thing or upsetting and spoiling the relationship with the client.

What they are discussing is: ‘Do you want me to let you die?’ How do they agree that without actually saying that? 

A case study is discussed...

John initially thought EOL support was to try and reverse the damage to his liver. The member of staff explained his medical treatment was only a small part of EOL support. He was encouraged by this and engaged well with support after returning to the hostel.

John’s care expectations were still there. He expected his health issues to be addressed.

Completing the EOL support plan with John helped him to realise the reality of his situation.

John’s grooming addressed and downsized his care expectations. He has realised the reality of his situation and no longer expects his health issues to be addressed following a curative route.

Although distressing, John said he was comforted that the right people would be informed. John continued to drink heavily and use heroin. He overdosed twice in a short space of time and had to be resuscitated using Naloxone. On one occasion staff administered 5 doses of Naloxone before the ambulance crew arrived. The paramedic administered more Naloxone and informed staff they had probably saved his life as he had gone over so far.

John OD'd twice and had to be resuscitated with Naloxone. This is another slip down the slope. If CPR isn't worth it, then is medicating Naloxone to bring him to?

A lack of understanding around supporting someone at the end of life, coupled with a limited awareness of the community services available, meant that the default position was to dial 999, meaning clients would end up in A&E. This often resulted in clients dying on a ward in unfamiliar surroundings, or discharging themselves back from where they came.

The community services are not available. This is the 'reality' of the situation: John has made his choice; one more slip down the slope and they'll let him go.

With the help of the care home education team, we explored how the six steps of the national EOL Care Pathway could be applied to support the staff in regular contact with this group.

Those who get into this sort of work to somehow retrieve this human flotsom and jetsum and restore them to some meaningful existence, like the beachcomber, have the gut instinct to toss the stranded starfish back into the sea.

‘I’ve not got long for this world’ can so often be met with ‘Don’t be daft, you’ll be around forever!’

That is the gut reponse; it isn't a cue for a chat about EoLC!

In all, the professionals working with alcohol users said they could now concentrate on the real care needed as they felt they had a voice to discuss the topic of death with their clients and clinicians. Work undertaken by St Mungo’s also helped to encourage local networks that the scope was there to make the necessary changes.

When you've hit rock-bottom, you need a help up. But is it easier and less challenging and cheaper to pick them off for EoLC than to pick them up for rehab?

Conversations around death and dying always were something of a taboo, but why more so for this cohort? The use of the ‘surprise question’, ‘Would you be surprised if the person in front of  you were dead in a year?’, was arguably difficult to apply to someone who regularly relies on substances. Is this the reason discussions about abstinence and managing drinking were more likely to occur than a dialogue facing the real dilemma around their inevitable EOL journey and death?

Grooming the groomers...

The ‘we can do this’ attitude and passion of hostel workers and health professionals providing EOL care led to a forum being formed to work through the barriers to overcome the many challenges. The group looked at issues around the confidence of hostel workers to begin or pick up on cues for EOL conversations, attitudes towards and the accessibility of palliative care and how the national drive for this group of people to ‘achieve their preferred place of care’ at the end of their lives could be achieved.

There is a 'national drive' to pick off all vulnerable groups.

So, now it’s been talked about, who needs to know and how is this information captured? It’s no good keeping all the information in the vaults of your organisation, seen by no-one other than hostel staff.

Information sharing...

If 999 is dialled, the ambulance crew need to know the patient they are attending actually doesn’t want to be carted off to A&E, to die in an acute hospital with no-one around them they know.

EoLC 'conflict'...

Staff are aware of the impact a death can have on other clients, especially for those where relationships have formed. They are now able to provide support to manage difficult feelings and emotions.

The regular forum meetings have provided the opportunity to discuss those ‘doubting Thomas’ moments, reflect and share good practice. They have also proved invaluable as an additional resource for practical and emotional support for the staff who have supported deceased clients.

Peer pressure and support in the forum meetings melds the group to its unified purpose.

Required reading -

Liverpool Care Pathway – The LCP Hit List

Liverpool Care Pathway – "Six Steps To Success"

Life is for living...

Will you be there for them for the journey?