Meeting the needs of patients in the last days of life: assisting health professionals deliver quality end-of-life care is the aim of the Liverpool Care of the Dying Pathway. A pilot project has been running in three aged-care facilities, two hospital wards and a hospice in Palmerston North.

Supporting colleagues to provide quality palliative care in a range of environments is a key role for palliative care specialists in New Zealand. This reflects a global trend to facilitate the transfer of palliative care best practice to other settings, so more people can benefit. The Liverpool Care of the Dying Pathway (LCP) (1) is gaining momentum in New Zealand as a tool by which this collaborative approach to meeting the needs of the patient in the last days of life can happen, irrespective of diagnosis or place of care.

Primarily through the rise of the hospice movement, palliative care has developed as a specialty in its own right, grounded in its own growing body of specialist knowledge. In New Zealand, palliative care has its own national strategy, (2) a recognised place in the cancer control strategy (3) and a growing influence on the quality of life of New Zealanders living with life-limiting illness. A collaborative model of palliative care has emerged that recognises the place and roles of both palliative care "specialists" (eg hospice and hospital palliative care teams) and "generalists", which includes aged residential care (ARC) staff, general practice teams, Maori health providers, district nurses and hospital clinical teams. (4) An important emerging role for specialist palliative care is to support generalist colleagues provide quality palliative care wherever the patient may be. This not only ensures the prudent use of specialist palliative care, it also validates the role of the generalist, who historically has always had a key role to play in end-of-life (EoL) care.

A significant number of New Zealanders die in acute hospital wards, ARC facilities or their own homes, the latter being the preferred place of death for many. (2,5) It is crucial providers of care have the skills, confidence and/or resources to deliver effective EoL care. There is some evidence that within ARC and acute hospital settings, significant issues can exist around the care of people who are dying, particularly in relation to time constraints, limited palliative care skills and a culture of care that can be at odds with the palliative approach. (6,7) There is also evidence that staff in these settings want to deliver quality EoL care and can find the limitations that exist both professionally and personally challenging. (8)

A desire to overcome many of these issues underpins the rationale behind the LCP. As a multi-professional document based around key goals of care, it provides an evidenced-based framework with measurable outcomes of care in the last days or hours of life. In essence it is a clinical guide for those caring for the dying, designed to support health professionals in their practice to ensure the needs of patients and their families are met.

How the tool was developed

The LCP was developed in Liverpool in the late 1990s as a tool to transfer hospice best practice in EoL care into other settings, to reduce barriers and improve accessibility to palliative care. (9) Its use has spread to hospital, ARC, community and hospice inpatient settings. To date, it has been implemented in 1300 sites in the United Kingdom (UK), as well as in at least seven other countries, including New Zealand. Evidence is growing that integrated care pathways such as the LCP are a way of improving quality of care. (10,11)

Palmerston North's Arohanui Hospice became involved with the LCP as part of its goal to develop an integrated model of palliative care in its region. This includes supporting generalist colleagues to meet palliative care need. While investigating and developing resources related to the LCP, an invitation to become a collaborating centre with Liverpool was accepted. Subsequently, an LCP project team was established and a pilot project developed. The project plan included implementing the LCP in the Arohanui Hospice inpatient unit, three ARC facilities and two acute wards within Palmerston North Hospital To achieve this, support was obtained from the Arohanui Hospice Service Trust, Palmerston North Hospital and the MidCentral Health District Health Board (DHB).

The project objectives are to:

1) improve the delivery and documentation of EoL care for patients, family and whanau dying in specialist and generalist palliative care settings;

2) ensure that care in the dying phase is informed by palliative care principles and approaches, thereby enhancing accessibility, equity and cultural awareness;

3) ensure the principles of specialist hospice/ palliative care best practice are disseminated and evidenced in documentation;

4) facilitate effective co-ordination of care, interdisciplinary communication and mutual understanding between clinicians working in specialist palliative care and those working in other settings; and

5) enable the development of demonstrable and measurable quality outcomes for the care of the dying.

By launching the LCP in the hospice inpatient unit first, substantial benefits were gained in adapting the document for use in New Zealand, developing expertise among the staff, obtaining evidence of outcomes, and obtaining a basis for ongoing service development and quality improvement. To date, the LCP has been implemented in three ARC facilities with hospital level care facilities and one acute inpatient ward at Palmerston North Hospital. The second ward and final site will begin using the LCP next month.

Research component

The aim of the associated research project is to gather information regarding staff perceptions of EoL care in their workplace before and after the integrated care pathway has been introduced. Of particular interest is the impact introducing the LCP has on staff knowledge, confidence, communication, and teamwork in providing EoL care. The research project is defined by the question: Do staff perceive that an integrated care pathway for the imminently dying patient, their family and whanau positively influences care?

There is considerable anecdotal and research evidence from overseas about the benefits of the integrated care pathway after it has been introduced. However, little research evidence is available regarding staff perceptions before and after introducing the pathway, and none within New Zealand. Research data includes surveys before and after the pathway is introduced and focus groups for staff post implementation. Results will be shared with the participating staff, organisations and published so it may inform others.

Use of the LCP in clinical practice

The LCP is a legal document that replaces all other clinical notes. In order to begin the LCP, the interdisciplinary team needs to be able to recognise when the patient is dying. This can be difficult. (12) A team approach should be used which unites the care given and avoids giving conflicting information. (13)

The LCP offers four criteria to guide the multidisciplinary team in recognising and diagnosing dying. Two of the following may apply:--

* The patient is bed bound

* The patient is semi-comatosed

* The patient is only able to take sips of fluid

* The patient is no longer able to take tablets.

When the decision is made that the patient is dying, the LCP clinical notes logically guide care using a series of specific goals and prompts. The document has three main sections:

1) Initial assessment

The interdisciplinary team completes this only once. It considers issues such as anticipatory prescribing, discontinuation of inappropriate nursing and medical interventions, assessment of spiritual, religious and cultural needs, and appropriate information sharing and communication.

2) Ongoing assessment

This prompts four and 12-hourly assessments (in primary care this occurs on each visit). Assessments include symptom management and ongoing physical and psychological care of the patient, their family and whanau.

3) Care after death

This prompts the team to complete associated practical tasks and assess the information and support needs of the family and whanau. (For an example, see figure 1.)

Figure 1: example

1) Initial assessment:

Goal: Current medication assessed and non essentials discontinued
Prompt: Appropriate oral drugs converted to subcutaneous route and
syringe driver commenced if appropriate. Inappropriate medication
discontinued.

2) Ongoing assessment:

Goal : Patient is pain free
Prompt: verbalised by patient if conscious. Patient is pain free on
movement, appears peaceful, consider need for positional change.

3) Care after death

Goal: Procedure for laying out followed according to policy
Prompt: Carry out specific religious/spiritual/cultural needs,
requests

(LCP version 11, 2005)

If a goal is not achieved or the pathway is not followed, this is documented as a "variance" This acts as a prompt to have the need addressed, eg pain relief given and the outcome evaluated.

Implementing the LCP

Implementing the LCP within an organisation requires a substantial commitment, a team approach and the support of the specialist palliative care team. (14,15) The first steps involve undertaking a baseline audit of documented EoL care. The next steps include modifying the prompts within the document to reflect local practice, providing education on the LCP and launching the document into actual use.

Following the established use of the pathway, a post audit is carried out from which a comparison with the baseline audit can provide a powerful demonstration of the difference the path way can make to documented care. Figure 2 demonstrates a typical picture reflecting data taken from the baseline audit (pre-implementation), and the post-implementation audit showing the pre-emptive prescribing of medications. These results provide the clinical team with a valuable opportunity for reflection and practice development. Sustainability of the pathway can then be enhanced through the integration of the LCP audit cycle into the organisation's regular quality improvement programme. In New Zealand the LCP has been implemented on a limited scale, mainly in hospice inpatient units but also in some ARC and acute settings. Some centres have employed nurses as LCP facilitators to support implementation, whereas others have endeavoured to implement it using existing resources. The level of implementation does not reflect the level of interest, however. This is demonstrated by the substantial number of inquiries received by the Arohanui Hospice team and large numbers attending workshops at the Hospice New Zealand Palliative Care and New Zealand Pain Society Conference in Dunedin at the end of 2006. There have also been discussions at national and regional levels to raise awareness of the LCP as an appropriate clinical tool to inform care and future health service planning.

Experience to date with the LCP has demonstrated that the hospice model of caring for the dying can be transferred to other settings through the use of an integrated pathway. (9) It is also clear the LCP offers much to support the emerging collaborative model between generalists and specialists in palliative care. Clinicians and health planners alike should seriously consider the growing evidence, along with the groundswell of interest, when measuring its potential benefit to patients. They should also ensure LCP development happens in a way that ensures its sustainability for the future. The challenge is to develop a resourced, sustainable model that ensures best care for the dying is not just achievable, but inevitable. (16)

The LCP Central Team in the UK offers support and project advice. Refer to the website www.mcpcil.org.uk.

This article was commissioned by the co-editors in February 2007.

References

(1) Ellershaw, J.E. (2002) Clinical pathways for care of the dying--an innovation to disseminate clinical excellence. Journal of Palliative Medicine. 5: 4, 617-623.

(2) Ministry of Health. (2001) The New Zealand Palliative Care Strategy. Wellington: author.

(3) Ministry of Health. (2003) The New Zealand Cancer Control Strategy. Wellington: author.

(4) Ministry of Health. (2006) Defining New Zealand Palliative Care (draft). Wellington: author.

(5) Ministry of Health. (2002) Health of older people in New Zealand: A statistical reference. Wellington: author.

(6) Watson J., Hockley J. & Dewar B. (2006) Barriers to implementing an integrated care pathway for the last days of life in nursing homes. International Journal of Palliative Nursing; 12: 5.

(7) Pincombe. J., Brown, M. & McCutcheon, H. (2003) No time for dying: A study of the care of dying patients in two acute care Australian hospitals. Journal of Palliative care; 19:2, 77-86.

(8) Hockley, J., Dewar. B. & Watson. J. (2005) Promoting end of life care in nursing homes using an 'integrated care pathway for the Last days of life'. Journal Research Nursing; 10: 2, 135-152.

(9) Ellershaw, Journal. & Murphy, D. (2005) The Liverpool Care Pathway (LCP) influencing the UK national agenda on care of the dying. International Journal of Palliative Nursing; 11: 3,132-4.

(10) Ellershaw, J.E., Wilkinson, S. (2003) Care of the Dying: A Pathway to Excellence. Oxford: Oxford University Press.

(11) Benton, D.C. (1999) Clinical effectiveness. In S. Hamer & G. Collinson (eds) Achieving evidence-based practice: A handbook for practitioners. Edinburgh: Bailliere Tindall.

(12) Higgs, R. (1999) The diagnosing of dying. Journal of the Royal College of Physicians; 33: 2, 110-112.

(13) Kinder, C. & Ellershaw, J.E. (2003) Now to use the LCP for the dying patient. In Ellershaw, J.E. & Wilkinson, S. (eds.) Care of the Dying--A Pathway to Excellence. Oxford: Oxford University Press.

(14) LCP Central Team UK. (2005) International information pack. Liverpool: The Marie Curie Palliative Care Institute.

(15) Mellor, F., Foley, T., Connolly, M., Mercer, V. & Spanwick. M. (2004) Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying. International Journal of Palliative Nursing; 10: 10, 507-509.

(16) Ellershaw, J.E. & Murphy, D. (2006) LCP Steering Group Annual Impact Report January 2005-December 2005. Liverpool: The Marie Curie Palliative Care Institute.

Barry Keane, RN, BA, PG DipHS, is director of clinical services at Arohanui Hospice in Palmerston North; Amanda Taylor, RGN, BA (Hans), PG Cert practice ed, is the Liverpool Care of the Dying Pathway facilitator, based at Arohanui Hospice; and Jean Clark, RN, BA (Hons), PhD, is the clinical nurse specialist in MidCentral District Health Board's hospital palliative care team. They are all members of the LPC project team.

Figure 2: (N&V = nausea and vomiting; RTS = respiratory tract
secretions)

Pre-implementation PRN drugs prescribed (n=20)

Percentage
Yes   No

Pain        40    60
N&V         40    60
Agitation   25    75
RST         35    65

Pre-implementation prescribed (n=10)

Percentage
Yes   No

Pain        100
N&V         100
Agitation   100
RST         100

Note: Table made from bar graph.