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OPINION

Liz Bryan: ‘The Liverpool Care Pathway failed because it oversimplified care of the dying’

End-of-life care is an art and adequate training is needed to deliver it, says Liz Bryan

I often hear it said – by those who can do it – that delivering adequate care to those approaching the end of life is not rocket science. I tend to agree but it is, nevertheless, an art. This is perhaps why the Liverpool Care Pathway has apparently failed in its purpose.

The LCP aimed to support health professionals unaccustomed to caring for the dying to manage the transition of the final stages of people’s lives through to death. However, it has oversimplified a process that requires a specific practical wisdom that is not necessarily present in all those who find themselves at the bedside of the dying.

 

‘Specialist practitioners thought that perhaps one way of transferring the model of care developed in hospices into hospital practice was by designing a step-by-step guide. There is absolutely nothing wrong with the guide but clearly it is not that simple to transfer the “art”’

When reflecting with students on the limitations of the LCP, I have used the analogy of the pilot of a light aircraft.

The plane seemed almost like an extension of himself. He was able to loop the loop and dive and even, if the fuel cut out for any reason, right the plane and safely land it with some degree of confidence.

Those who watched on the ground admired his skill and asked him to show them how to do the same. Because it seemed so easy to him, he thought all he needed to do was write down the instructions in “easy” steps for them to follow.

The novice pilots took the planes up into the air and, as long as all went smoothly, were able to land – but very few were able to get the plane out of difficulty and many crashed. The pilot had underestimated his tacit knowledge acquired over time and through experience.

In this way, specialist practitioners thought that perhaps one way of transferring the model of care developed in hospices into hospital practice was by designing a step-by-step guide. There is absolutely nothing wrong with the guide but clearly it is not that simple to transfer the “art”.

In 1978, Carper spoke of the “fundamental ways of knowing” in nursing; these are not only empirical (that is, factual knowledge that can be empirically verified) but personal (the ability to imagine oneself in a situation), ethical (awareness of moral questions and choices) and aesthetic (being able to relate to the uniqueness of a given situation in its wholeness). She presented this typology as a tool for generating clearer, more complete thinking, and for learning about experiences. It led to a reaction in nursing against overemphasing knowledge that was solely empirically derived – so-called “scientific nursing”.

By emphasising that attitudes and actions that are perhaps more personal and more intuitive are also centrally important, the concept of “reflective practice” in nursing was further developed. This principle is of even greater significance when the learning is associated with an area of practice as potentially emotive and complex as caring for the dying.

Through an end-of-life care educational initiative designed to be delivered by hospices to nurses working in acute settings, the value of role-modelling and providing a safe and supportive learning environment in which to reflect and make sense of experience has yet again been proven. The Quality End of Life Care for All programme acknowledges the need for professionals to be shown how to provide care for those who are approaching the end of life and their families. These professionals then need to be accompanied as they try out their new learning and develop skills appropriate to the setting in which they work.

Hospices – there are 220 hospice inpatient units in the UK – are almost exclusively third sector and are only able to provide specialist care to approximately 7% of the population. They are a valuable educational resource and, as yet, largely unrecognised and certainly underutilised.

QELCA invites acute hospitals to release teams of clinical nurse managers from the same department or clinical directorate to spend one week in small groups on placement at their local hospice.

Specially trained hospice nurse trainers then facilitate a combination of ward experience and in-depth reflection. The same facilitators then provide ongoing support in collaboration with hospital specialist teams over the following six months.

Piloted so far with more than 20 hospitals, the evidence suggests that this mode of education delivery does change attitudes and empowers practitioners to change not only their own practice but also to lead change for their teams and within their organisations (See http://www.stchristophers.org.uk/qelca).

Liz Bryan is lecturer practitioner in palliative care at King’s College London’s Florence Nightingale School of Nursing and Midwifery and St Christopher’s Hospice

Reference

Carper B (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science ;1: 1, 13-24.

Readers' comments (68)

  • Excellent article and analogy. Keep up the good work Liz & Co.

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  • quick reflection - will read article and hopefully more comments in detail later but I think we need to be very careful about mechanising and protocolising many aspects of healthcare, which the LCP appears to do if not fully understood and reflected on, and especially at the end of life.

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  • talk about stating the obvious! As a member of my local end of life forum I have been to many many workshops, training sessions etc around the LCP and in every single one the necessity for underpinning training and knowledge to support staff in the correct use of the LCP has been highlighted. Without that, yes, it becomes yet another tick box exercise.

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  • Anonymous | 13-Aug-2013 4:50 pm

    it clearly is not obvious to everybody otherwise there would be no issue. as you say, training is neccessary which appears inadequate or lacking in some places.

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  • "QELCA invites acute hospitals to release teams of clinical nurse managers from the same department or clinical directorate to spend one week in small groups on placement at their local hospice."

    Why? They almost exclusively have nothing to do with the delivery of patient care. Send the nurses who actually carry out the care! But look at the other issues surrounding end of life care, like lack of staffing and availability of clinical support. Stop expecting nurses to do the impossible with nothing.

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  • Thank you Liz

    The real question to ask is whether "end of life care" can ever be successfully provided within the context of a busy acute ward environment !

    My own belief is that provision of dedicated hospices should be expanded and fully funded by the NHS -------

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  • Very good article. Thank you.
    I agree with Jenny above.
    Having worked in hospice care, with a grounded emphasis in end of life care and most recently in a busy acute ward. There is no realistic translation when using the LCP.
    An alternative is required, but it should be tailored to the environment. A generic form/pathway designed to deal with the complex needs of irrevocably dying patients cannot be tick-boxed in or out of vogue.
    I sincerely hope that an experienced, practicing and progressive nurse takes a lead in creating the new pathway/guidelines/strategy, etc.

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  • tinkerbell

    I agree with Jenny and above anonymous. I do not have much experience with LCP but it is not hard to imagine that a busy medical ward may struggle to provide the specialism and time that is needed.

    It is only right that those who have the specialist knowledge and experience be heard and listened to on this one so that we get it right, otherwise all talk of dignity of care without the proper environment and staffing to provide that care, once again, becomes rhetoric.

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  • care of dying patients used to be an integral part of nursing training and many were very good at it.

    although acute wards do not provide the optimal environment for this type of care it is inevitable and often without being left any choice that some patients will die there and it is up to nurses to do their very best as they have always done but it requires time to provide this unrushed type of care for the patient and their family. obviously this depends upon, like all nursing care, enough staff. it maybe that training also needs to be re-examined to ensure it is adequate to cope with the changes in this environment.

    If the LCP is to be continued successfully or any further instrument or new methods and developments are introduced then obviously additonal comprehensive training in their use is essential and it should go without saying that clear, open, transparent and honest communications are vital with all concerned and involved in their care at every stage of the care in response to each patient's changing condition and the needs of their families and the team supporting and caring for them.

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  • michael stone

    The LCP seems to have mainly failed for 2 reasons.

    1) The LCP tried to describe an 'approach/mindset' for EoLC, but inadequate staff expertise in acute settings often led to the LCP being seen as ' a set of instructions';

    2) Nurses and doctors in hospices, usually have significantly more time to spend with individual patients and their families, than nurses and doctors in acute settings: 'time with, and listening to, the patient/family' is crucial if EoLC is going to 'work okay' - even if you do 'understand it all' you couldn't 'do it right' without enough 'time'.

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  • M. Stone

    to registered nurses the failures are already obvious and there are more than the two reasons you mention and which have already been discussed.


    There is not necessarily a lack of expertise in EoLC in acute settings but rather a lack of resources preventing the delivery of adequate care in areas where acutely ill patients often need priority in order to save their lives or prevent them from rapidly deteriorating. this often results in urgent and immediate action taking staff away from other patients and tasks and especially when they are in insufficient numbers.

    as I said above people do unfortunately die in acute settings.
    hospices are mainly for terminal care and for deaths which are expected and are obviously organised differently and equpped for what is one of their main roles.

    Acute care and palliative care in hospitals have two totally different functions.

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  • Anonymous | 13-Aug-2013 9:36 pm

    As a hospice that provides the QELCA programme we have found that most of the nurses who attend the programme are at Staff Nurse or Senior Staff Nurse grade. The encouraging aspect for us is that their nurse managers (and Chief Executive)recognise the importance of attending the training programme and supporting the ideas the nurses bring back into their own areas which will improve end-of-life care.


    Jenny Jones | 14-Aug-2013 3:02 am


    My own belief is that provision of dedicated hospices should be expanded and fully funded by the NHS -------

    NO, having worked in the NHS for most of my career the last thing we should consider is having hospices fully funded by the NHS. My experience is that the freedom to act outsuide of a tick-box culture and provide outstanding compassionate care unhindered by the NHS bureaucracy is one of reasons why hospices work so well.

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  • tinkerbell

    Robert I agree with you that OUR NHS is hindered by bureacracy, so much is duplicated and triplicated to the point that paperwork comes before the patient. How much more efficient we could be without unnecessary bureaucracy.

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  • Robert Standfield

    Clearly you wish to condemn the majority of terminally ill people to less than adequate care.

    The "tick box" culture you describe has been imposed on nurses by nurses !

    Get a grip man !

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  • While I agree with the sentiments about EOL care being an art and education being important. I disagree that the LCP failed. I think it is an excellent framework for care and in the vast majority of cases has improved care. It is just the latest victim of the ongoing nhs media witch hunt. Lets hope that medics, particularly in acute areas learnt something from the pathway and don't regress to the old aggressively treat until death mentality.

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  • As a student nurse my main concern is that if we replace the LCP, what will replace it with, how much will it cost? and what strategies will be put into place to help prevent the new documentation being misinterpreted? There are many shortfalls financially in the NHS at the moment and with this in mind would it be far better to provide more acceptable training in facilitation of the LCP as previously mentioned, rather than spending money we clearly do not have on generating yet another piece of documentation which could also fall foul of misinterpretation and not be used as it was deemed fit for purpose.

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  • The LCP didn't fail in many circumstances. Overall there was inadequate training, and the Daily Mail led a campaign to discredit making the LCP sadly a toxic product. Liz Bryans article is excellent with a title that doesn't reflect the content...she has not said the tool oversimplified dying. What I took from it was that the LCP was a good tool but lacked appropriate training particularly role modelling and was suggesting hospices have an important role to play, they are an untapped resource to the NHS.

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  • I work as a community nurse and we have used the LCP many times to support and care for people at the end of life and also their families at this very emotional time. It works really well in this environment and all involved in delivering care know exactly what to do and when. I had a personal experience when my father in law was dying at a weekend in hospital. No one would take responsibility for commencing the pathway because the consultant was not available and as a result he spent the last two days of his life in agitation and dreadful pain. If we are going to use any kind of nursing tool in the future to manage end of life care everyone involved needs to have experience and understanding of patient needs at this time. Mostly comfort and kindness.

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  • The doctors also deserve to be fully trained and supported in EoL care as they are as involved as the nurses are in patient care.
    Of course all nurses should attend EoL courses, training days, placements - shouldn't this start though at student level, I spent 3 months working in a hospice during my student days back in the 80's. They were the days of Ropers Model where the Death and Dying 'box' rarely got a mention so maybe we've never really been comfortable with this.

    There need to be more hospice or EoL beds made available, it's not realistic to expect no-one will die in an acute ward or environment, hospitals are for sick people and some people will die, we need to make it as comfortable and peaceful for them and their families as we can, we can't do that in the current bed or understaffing situation.

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  • everybody professionally involved in care of the dying must be adequately trained. this includes nurses, doctors and all other clinical staff as well as those involved with this group including anciliary workers and the clergy.

    the catholic priest in our hospital spent much of his time accompanying patients who were terminally ill and dying and their families and was brilliant. anything under the sun could be discussed with him and religion was never mentioned unless it was the patient and their family's wish.

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