Liverpool Care Pathway

1. Liverpool Care Pathway Central Norfolk Specialist Palliative Care Team Presentation to Watton medical practice 18th February 2008 Elizabeth Stallwood

2. 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)

3. Background • The LCP is now seen as best practice for end of life and is a major government initiative with PPC and GSF. It is expected to be used for all patients who are dying. • The process of evaluation for any organisation can begin with a retrospective audit of 20 case notes (Base Review) to establish current documentation of care. This forms part of a national audit programme • The development of the LCP has led to measurable outcomes of care

4. 3 sections of the LCPAll care is now directed at comfort and dignity Sections: • 1.Initial assessment: medical and nursing • 2.Ongoing daily assessment • 3.care after death Goals encompass the following: - • Physical : Medications and comfort care • Psychological: Resolution of tensions • Religious / spiritual: peaceful outcome. • Social: All family understand the care.

5. Section 1:Initial assessment 1.Diagnosis of dying:unable to take tablets, bed-bound, semi-conscious, only able to take sips of fluid.2.Drug review3.Anticipatory prescribing4. Nursing review

6. Approaching death Multiple organ failure Metabolic disorder Organic brain failure Gradual shutdown of body function

7. Medications Goal 1 Current MEDICATION assessed and non- essentials discontinued Patient not taking oral medications nb Insulin (see protocol) Dexamethasone (separate driver) Anti convulsants – midazolam 20mgs

8. Medication review 1 Goal 2 a AS REQUIRED subcutaneous drugs written up according to protocol 2.1 Pain 2.2 Nausea and vomiting 2.3 Agitation 2.4 Respiratory tract secretions 2.5 Dyspnea nb remember any anticipated emergency drugs. Goal 2b Anticipatory drugs for syringe driver prescribed for all the above symptoms with ranges for increasing the drug

9. Drug protocols: Nausea and vomiting

10. Drug protocols: Respiratory tract secretions

11. Medical review 2 Goal 3: DISCONTINUE inappropriate interventions 3.1 Blood tests 3.2 Antibiotics 3.3 IV/ S/C fluids or drugs (A/B) 3.4 Not for CPR ( GSF/PPC/ACP) Doctors signature……………………………………………………..date……

12. Nursing interventions Goal 3a Discontinue inappropriate nursing interventions Goal 3b Syringe driver set up within 4 hours of Doctor’s order

13. Psychological/Insight & Religious/Spiritual Goal 4 Ability to communicate in English assessed as adequate: 4.1 Patient 4.2 Family/other Goal 5Insight into condition assessed: Aware of diagnosis 5a1 Patient 5b2 Family/other Recognition of dying: 5b1 Patient 5b2 Family/other Goal 6 Religious and spiritual needs are assessed 6.1 Patient 6.2 Family /other

14. Communication Goal 7 How family/other to be informed of patients impending death, any special people OOHs. Goal 8 Bereavement : anticipate those at risk Family/other given information, ie what to do after death hospice leaflets Goal 9 Ensure General practitioner is aware of patient’s condition Goal 10 Plan of care explained to: 10.1 Patient 10.2 Family Goal 11 Family/other understanding of care plan

15. Section 2: Assessment and Ongoing Care a Daily review of symptoms and conditionb Note a varience if not meeting the goal

16. Assessment and Ongoing Care Are Goals are met on • Pain, agitation, respiratory tract secretions, nausea and vomiting • Mouth care, micturition, medication given safely and accurately, syringe driver checked (where appropriate), bowels assessed

17. Section 3:Care After Death Goal 12 GP practise contacted re: patients death Goal 13 Procedure for laying out followed Goal 14 Procedure following death discussed -to include OOHs. Goal 15 Family/other given information on procedures Goal 16 NOT APPLICABLE TO COMMUNITY SAMPLE Goal 17 Necessary documentation and advice is given to the appropriate person Goal 18 Bereavement leaflet given

18. Conclusions The Liverpool Care Pathway for the Dying prompts the following KEY FUNCTIONS: • DIAGNOSIS of dying • ANTICIPATION and PLANNING of the appropriate care • DISCUSSION with patients and relatives about the care (sometimes difficult conversations + DNAR) • METICULOUS practice at this precious time