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Dr Rosalie Dunn Macmillan Palliative Care GP Facilitator NHS Lanarkshire

Caring for people who are dying Reflections on the Liverpool Care Pathway (LCP) A doctor’s perspective. Dr Rosalie Dunn Macmillan Palliative Care GP Facilitator NHS Lanarkshire. Background to LCP. Keri Thomas Macmillan Facilitator

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Dr Rosalie Dunn Macmillan Palliative Care GP Facilitator NHS Lanarkshire

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  1. Caring for people who are dyingReflections on the Liverpool Care Pathway (LCP)A doctor’s perspective Dr Rosalie Dunn Macmillan Palliative Care GP Facilitator NHS Lanarkshire

  2. Background to LCP • Keri Thomas Macmillan Facilitator • Gold Standards Framework: Communication Coordination, Continuity of care, Control of symptoms, Care for the Carers, Continuing education • John Ellershaw Professor of Palliative Medicine Marie Curie Institute Liverpool • Care of the Dying

  3. Liverpool Care Pathwayfor the Dying Patient • A framework to provide the best possible care in the last few days of life • Sensitive communication with family/carer is essential • Decision by senior doctor and care team • Not always an easy decision especially in non cancer patients To bring hospice standard of care to all • Only for people whose condition is not reversible, all reversible causes having been excluded (CELT Forth Valley) • Patients should be involved in decisions, if possible

  4. Newspaper headlines • Sentenced to death on the NHS • Care? No, this is a pathway to killing people that doctors deem worthless • End of life row ‘causes public fear’ • Hospitals treating the Liverpool Care Pathway as just another ‘thing to do’ • How I saved my father from the Liverpool Care Pathway two years after mother endured ‘agonising’ death on the system

  5. Newspaper headlines • Police probe the death of mother on ‘Care Pathway’: son claims ‘cruel’ withdrawal of fluids and food was ‘attempted murder’ • District Nurse put 90 year old father on the Liverpool Care Pathway in his own HOME without consulting his family • Moments after coming off the Care Pathway, my mother was enjoying a G+T and scrambled eggs - and lived for another seven precious weeks

  6. What does/does not happen? • LCP is not designed to hasten death • No need to withdraw fluids/nutrition – balance of good and harm (e.g. fluid in lungs). Keep mouth moist to avoid discomfort • Family/carer should always know about LCP • Difficult to predict death, so possible to start LCP and stop if recovery begins • None of the recent media coverage relates to Lanarkshire patients

  7. Where we use the LCP • Community • Care Homes • Hospitals

  8. Criteria for use of the LCP The multiprofessional team has agreed that the patient is dying and two of the following must apply • The patient is bed bound • Only able to take sips of fluid • Semi-comatose • No longer able to take tablets

  9. LCP • All personnel must sign paperwork • Three sections • Initial assessment ,with 11 goals for achieving maximum comfort levels • NB goal 10 plan of care explained and discussed with patient and/or family • goal 11 family/other express understanding of planned care

  10. Section 2 Ongoing assessment • 14 goals to ensure patient is symptom free and the family/carer are prepared for the patient’s imminent death • Including holistic assessment of all symptoms and covering psychological and spiritual aspects and especially attending to the needs of the family/carers

  11. Section 3 Care after death • 7 goals • all procedures following death to be discussed and bereavement leaflet to be supplied to family/carer

  12. Variance analysis • If a goal on the LCP is not achieved this should be coded as a ‘variance’ • Clinicians are encouraged to note what variance has occurred and why. What action was taken and the outcome

  13. David Brown’s experience

  14. Audit of family/carer involvement in the LCP in Lanarkshire • Was the family aware of the diagnosis? • Yes 88% No 2% Not recorded 10% • Did the family recognise the person is dying? • Yes 88% No 2% Not recorded 10% • Was the plan of care explained to and discussed with the family? • Yes 87% No 1% Not recorded 11% • Did the family express understanding of planned care? • Yes 82% No 1% Not recorded 17%

  15. Areas to address • Living Wills • Anticipatory Care Plans: covering Next of Kin, Preferred Place of Care, DNACPR, Guardianship/Power of Attorney, Just in Case prescriptions • Public Debate with media involvement

  16. Implications for the future • Dame Julia Neuberger to lead major enquiry into LCP acceptability in England • Lanarkshire and Glasgow subgroup responsible for reviewing End of Life guideline ?should consider new title e.g. “End of life Priorities” • Far earlier discussion of issues around Death and dying

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