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Guidelines published in wake of Liverpool Care Pathway phase-out announcement

Clinicians should go “out of their way” to check if end of live care patients and their families have any concerns, whether or not the Liverpool Care Pathway is being used, according to NHS England.

It highlighted that they may be experiencing “increased anxiety” resulting from the “heightened awareness about the LCP at the moment”.

NHS England has published a short guideline for “doctors and nurses caring for people in the last days of life” – in the wake of the government’s announcement earlier this week that the LCP was to be phased out over the next six-12 months.

The guidance stated: “Where the LCP is being properly used, this must not stop abruptly. The principles of good palliative care, on which it is based, must continue to be upheld: regular assessment and management of symptom control and comfort measures, effective communication with patients and their families, and provision of psychological, social and spiritual support.

“These principles hold true, whether or not the LCP or any integrated care pathway or plan for the dying is used. In keeping with standard good practice, a named senior clinician should be accountable for the care of the individual patient.”

The NHS England guidance noted that for patients who are currently on the LCP, nurses and doctors should:

  • Continue to reassess the patient regularly and frequently
  • Ensure a consultant review of the decision for the patient to remain on the LCP
  • Ensure that the patient’s family is aware that the patient is on the LCP
  • Communicate with the patient (wherever possible) and family/carers regularly to address questions or concerns about any aspect of care, or the LCP itself
  • If a patient remains on the LCP, continue to implement it properly
  • If a patient comes off the LCP, continue to pay attention to, and address, symptom control, comfort measures, and psychological, social and spiritual care, alongside any other treatment
  • Reassess the patient regularly and frequently so that the care plan can be adjusted

The announcement the LCP was to be phased-out followed the publication of findings from an independent review, headed by Baroness Julia Neuberger, which was set up to investigate concerns that the pathway was flawed.

The review concluded that in the right hands the LCP helped patients have a dignified and pain-free death. But it also found too many cases of poor practice, especially relatives not being properly engaged.

The review concluded the LCP should be “replaced by a personalised end of life care plan, backed up by good practice guidance specific to disease groups”. It also called on the Nursing and Midwifery Council to urgently issue guidance on end of life care.

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Readers' comments (3)

  • michael stone

    ‘Ensure that the patient’s family is aware that the patient is on the LCP, understands the reason and purpose of this, and agrees with this decision.’

    &

    ‘Reassess the patient regularly and frequently so that the care plan can be adjusted, taking into account the patient’s wishes (where known) and family’s views, especially their knowledge of the patient’s wishes.’


    Read those (for patients already on the LCP) - this is the bit where the clinical establishment flounders: you cannot ENSURE agreement with a decision (the first of the two above) and the reference to ‘their knowledge of the patient’s wishes’ in the second sentence is crucial, but again ‘it stops short of being clear’.

    The ONLY WAY to make sense of the Mental Capacity Act, is to START from ‘If we can be reasonably certain of how this incapable patient would answer, if he somehow could tell us, we must behave as if he were capable, and had answered in that way’.

    So THE LOGIC is as follows for patients who are mentally incapable, and had not previously made their wishes clear:

    1) The MDT ‘considers treatments, and predicts prognoses;

    2) These possible treatments and clinical outcomes, are then described by someone (often the senior clinician) to ALL of the available people (the family and friends), who know the patient well enough personally, to have a valid opinion ‘about how the patient would have answered, if you had asked him’.

    Now, it gets tricky if there isn’t full agreement of the answers the ‘family and friends’ supply in stage 2 (and it ISN’T a vote – everyone arrives at an individual answer) but if they ALL say ‘he would accept the suggested treatment’ or they ALL say ‘he would refuse the offered treatment, the next step is obvious (to me, anyway).

    You record the discussion, who was involved, and the unanimity of the responses to step 2 – then you behave as if that unanimous answer was ‘an answer directly from the patient’: but YOU DO NOT CLAIM THAT ANY INDIVIDUAL ‘MADE THE DECISION’.

    As I’ve said, the rest of the more complex situations can be analysed, but if you want to see it, email me at stone@stribmail.com


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  • The expression 'throwing the baby out with the bathwater' springs to mind here (and then throwing the bloody bath out as well!)

    Does anyone really believe that a fragmentary approach involving hastily cobbled together care plans and 'urgently' drawn-up guidance from the NMC will be any substitute for a long-established, quality-assured and internationally recognised tool to guide and document best practice in end of life care?

    Things can only get worser...

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  • michael stone

    Anonymous | 19-Jul-2013 4:30 pm

    'hastily cobbled together care plans and 'urgently' drawn-up guidance from the NMC'

    isn't the way to go - in fact, PLANS isn't the way to go, because 'following a plan' conflcits with 'providing personalised to the patient (in a wider than merely clinical) behaviour and ongoing and real-time responsiveness'.

    It is stressing the PRINCIPLES which is the way to go - basically, the concept is simple: if the patient is dying, is the patient less distressed as he dies because of what you are doing (compared to if you were doing nothing, and were not involved at all) ? If he isn't less distressed, then whatever you are doing is pointless - and if he is more distressed than he would have been had you not been doing anything, then you are doing a worse-than-uselss job, however well you might be following 'a plan/tool/piece-of-written-nonsense'.

    People only die once, and the important bit is the patient's experience of his/her own death: not whether you have 'followed your guidance' or 'ticked all the boxes' - 'Would s/he have thanked me for having done it ?' is the crucial question.

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