Improving practice with the Liverpool Care Pathway
The Liverpool Care Pathway can help to improve nursing practice
VOL: 101, ISSUE: 35, PAGE NO: 36
Amanda Taylor, BA, Dip(Ed), RGN, is Macmillan clinical nurse specialist in palliative care, and Liverpool Care Pathway facilitator, Daventry and South Northants PCT
The NHS Cancer Plan (DoH, 2000) states that ‘the care of all dying patients must improve to the level of the best’. It is well recognised that the hospice movement provides high-quality care for the dying (Ellershaw, 2000). The Liverpool Care Pathway for the Dying Patient (LCP) was created by the Royal Liverpool University Trust and the Marie Curie Centre in Liverpool. The aim of the LCP is to transfer the hospice model to other health care settings (Ellershaw, 2003). The LCP is an evidence-based document used to guide the care of dying adult patients, while providing measurable outcomes of care (Ellershaw et al, 2001).
The NHS Cancer Plan (DoH, 2000) states that ‘the care of all dying patients must improve to the level of the best’.
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It is well recognised that the hospice movement provides high-quality care for the dying (Ellershaw, 2000). The Liverpool Care Pathway for the Dying Patient (LCP) was created by the Royal Liverpool University Trust and the Marie Curie Centre in Liverpool. The aim of the LCP is to transfer the hospice model to other health care settings (Ellershaw, 2003). The LCP is an evidence-based document used to guide the care of dying adult patients, while providing measurable outcomes of care (Ellershaw et al, 2001).
The LCP is a key stage of the Gold Standards Framework (Thomas, 2003) and is recommended in the NICE Supportive and Palliative Care Strategy (2004).
Primarily designed for patients with cancer, the LCP is increasingly being used for patients who are in the last days of life regardless of diagnosis.
When to put a patient on the LCP
Recognising that a patient has entered the dying phase can be difficult (Higgs, 1999). A team approach to diagnosis should be used, as this unites the care given and avoids giving conflicting information to the family (Kinder and Ellershaw, 2003).
A diagnosis of dying is made when the multiprofessional team agree the patient is dying and 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.
How does it work?
The LCP replaces all other forms of documentation when the patient has been diagnosed as dying. Many nurses feel it makes documentation more accurate and less time consuming, and so means more time can be spent with patients and families.
The LCP is a legal document that every member of the multiprofessional team works with. It has three main sections:
1. Initial assessment;
2. Ongoing assessment and care;
3. Care after death.
The LCP is presented as a series of goals and prompts to act as a guide. Initial assessment is completed only once and ongoing care is assessed at least four-hourly. If a goal is not achieved or the pathway is not followed, then the health professional documents the reason for this as a ‘variance’. The LCP can be discontinued, for example if a dying patient improves.
How is it implemented?
The Liverpool Marie Curie Cancer Centre offers foundation and advanced training days for those considering implementing the LCP. For information refer to the www.lcp-mariecurie.org.uk website.
Has it changed practice?
In the author’s experience, implementing and using the LCP in two hospices, one community hospital and six wards in a district general hospital, has changed practice positively.
As an example, practice for the prescribing of ‘as required medication’ (PRN) for patients who are dying of non-malignant disease has changed substantially. The LCP prompts the prescription of PRN medication for four of the main symptoms that may be experienced in the last days of life (Turner et al, 1996).
The suggested PRN prescriptions for the four symptoms are shown in Box 1 (Glare et al, 2003).
Figure 1 reveals that with pre-implementation of the LCP, patients with non-malignant disease rarely had PRN medication prescribed for pain, nausea and vomiting, agitation or respiratory tract secretions (RTS). Post-implementation of the LCP, patients with non-malignant disease had PRN medication prescribed much more regularly.
The prescription and administration of PRN medication for patients with non-malignant disease is perceived by clinical staff as one of the major achievements of the LCP, which in turn directly improves the care of the patient and family.
Jack et al (2003) conducted a qualitative study using focus group interviews to explore hospital nurses’ perceptions of the impact of the LCP. The results suggested that the nurses had generally found that the LCP had a positive effect on patients and their families as well as on the nurses and doctors themselves.
What are the disadvantages?
Kelly (2003) comments that care of the dying may be ‘standardised to such a degree that reality is reduced to a flow diagram and palliative care is simply a series of boxes to be ticked by professional care givers’.
Without a robust implementation and education strategy the LCP could be at risk of becoming a ‘series of boxes to be ticked’. It is crucial that the health care worker understands the background and principles of palliative care and the LCP in order to use the document to its full potential. It should be used for guidance when offering high-quality, individualised care.
The LCP empowers nurses and doctors to deliver high-quality care to dying patients and their families. It facilitates and focuses multiprofessional communication and documentation, integrating national guidelines into clinical practice. The project also provides a focus for education and demonstrable outcomes to support clinical governance.
Caring for dying patients should be every health care professional’s business and a core competency. It is not just the job of hospices to care for patients that are dying - the reality is that the majority of deaths occur in the acute setting.
It is imperative nurses are equipped with the skills and knowledge necessary to offer the basic human right of high-quality care at the end of life. The LCP offers opportunities to implement this irrespective of diagnosis or place of death.
This article has been double-blind peer-reviewed.
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