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Care of the dying must be part of mandatory training


The recognition and diagnosis of dying is always complex, irrespective of previous diagnosis or history, and uncertainty is an integral part of dying.

The aim of the Liverpool Care Pathway for the Dying Patient (LCP) - a continuous quality improvement programme - is to apply the excellent model of hospice care for the dying to other healthcare settings using an integrated care pathway.

The LCP document guides and enables healthcare professionals to focus on care in the last hours or days of life when death is expected. This promotes high quality care that is tailored to the patient’s individual needs.

A major cultural shift is required if the needs of dying patients are to be met and the workforce is to be empowered to take a leading role in this process. Dying patients are part of the population of clinical settings.

‘Using the care pathway in any environment requires ongoing assessment and involves regular reflection, challenge, critical decision making and clinical skill’

We need to ensure high quality care for our dying patients and their relatives or carers. The LCP captures the hearts and minds of clinicians to respond to and influence policy to make a lasting difference at the bedside.

Care of the dying is urgent care. It must be seen as part of the core business of an organisation - training in end of life care must be a priority.

The pathway can improve quality of care, while increasing productivity and using innovation to encourage and embed sustainable change.

The LCP generic document is only as good as the teams who are using it. Using the care pathway in any environment requires ongoing assessment and involves regular reflection, challenge, critical senior decision making and clinical skill, in the best interest of the patient.

Implementing the LCP programme will create a change in the organisation. Recognition of the fundamental aspects of a change management programme is pivotal to success.

The responsibility for the use of the LCP as part of a continuous quality improvement programme sits within the governance of an organisation, and should be underpinned by robust, ongoing education and training.

I believe that all healthcare professionals should have training in care of the dying provided as part of an organisation’s mandatory training programme.

The LCP central team coordinates the LCP programme which sits within the Marie Curie Palliative Care Institute Liverpool (MCPCIL).

The LCP generic version 11 has been under review since December 2007 as part of extensive consultation. The LCP generic version 12 reflects the feedback from this as well as the latest evidence (see

The ethos of the LCP generic document has remained unchanged. However, in response to the consultation - which included carrying out two rounds of the National Care of the Dying Audit - Hospitals by MCPCIL and the clinical standards department of the Royal College of Physicians - the generic version 12 has greater clarity in key areas, particularly in communication, nutrition and hydration.

Care of our dying patients and their relatives or carers can be supported effectively by either version of the Liverpool Care Pathway.

We believe as with any evolving tool or technology, that those organisations who are using the LCP version 11 will work towards adopting version 12. As with all clinical guidelines and pathways, the LCP aims to support but does not replace clinical judgement.

The pathway is not the answer to the challenge of providing good quality care of the dying in our society but it is a step in the right direction; it has been recommended as a national and international best practice model for care in the last hours or days of life.

However, success is a journey - not a destination - and the road to success is always under construction. We need to continue to build on the evidence base to drive up quality care for all dying patients for this generation and the next.

The LCP Continuous Quality Improvement Programme

● To improve care of the dying in the last hours or days of life

Main themes
● To improve the knowledge related to the process of dying
● To improve the quality of care in the last hours or days of life

Main sections
● Initial assessment
● Ongoing assessment
● Care after death

Key domains of care
● Physical
● Psychological
● Social
● Spiritual

Main requirements for organisational governance
● Clinical decision making
● Management and leadership
● Learning and teaching
● Research and development
● Governance and risk

Deborah Murphy is directorate manager specialist palliative care, Royal Liverpool and Broadgreen University Hospital Trust, associate director, Marie Curie Palliative Care Institute Liverpool, and lead nurse for the Liverpool Care Pathway


Readers' comments (21)

  • Can someone please tell me where such trainins is being done,i would like to attend one.I work in a nursing home and I too, strongly feel all healthcare/social care staff need to have adquate knowledge in the end-of-life care issues.
    By the way i live in the East Midlands.

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  • my father died recently in Taunton Musgrove Hospital, he was terminally ill and spent his final two days of life in agony on an inappropriate surgical ward. The LCP was not even mentioned until the 2nd day and even then was properly implicated until he was was moved onto an oncology ward where he died hours later. The anguish suffered by the family of witnessing a loved one dying in pain and begging for help which never came will remain with us forever, training in end of life care must be improved urgently.

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  • That is so sad! I have seen such things many times. There is no excuse for such poor care. We are supposed to be advocates for our patients.

    As a student I am on my second placement at a hospice and know it can be done well. We need to value EoL care and hospices offer great training. Contact a local one and see what they have coming up.

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  • Whilst it has been a long time coming, at last there is a greater awareness of the need to raise standards of care for the dying. However it needs to consistent,and quality care should be delivered irrespective of where one dies. The care should meet their individual needs;holistic care being key. Mandatory training is needed for all persons coming into contact with the dying person, and their families. Obviously this needs to be tailored dependant on the role. Receptionists, maintenance, kitchen and laundry staff play an important part in delivering care, not just nurses, carers and doctors. Staff also need appropriate support. The LCP is a valuable tool, as is the Gold Standards Framework. Many PCTs have EoLc Facilitators who can be asked re. training, as well as the local Hospice. Having facilitated the GSF in Care Homes Programme I can recommend considering joining this programme, as it helps to look at a persons needs much earlier than in the last few days. This gives a team the opportunity to provide care that is truly person-centred. There are no second chances to get it right, we owe it to those we care for to work together as professionals to always strive for the best. Here's hoping the GMC guidance leads to doctors being consistent in taking a more active part in helping the dying person receive care that takes into account their wishes and preferences, having taken the time to explain their situation and options. I just worry that time will be used as an explanation for not discussing end of life issues with certain sections of society, for example the elderly. Let's hope.

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  • Peter Goble

    It would help if the basic message of articles like this could be stripped of corporate-speak such as 'change-management being pivotal to success' and 'success is not a destination, it's a journey'.

    What do these cheesy exhorations add to the basic message? Nothing, in my opinion, they just sound patronising and aloof.

    As the chairman of a hospice charity and a practising nurse with experience of end-of-life care in residential care, I suggest that well-meaning EoL practitioners get out more to talk to front-line workers, fillet the business-speak from their offerings, and innovate away from tired 'mandatory training' slogans.

    Believe me, these often sound like more jobs for box-tickers than anything that will "drive up" the yards of "standards" everyone is made to labour under in these target-blighted days.

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  • i think this training will be valuable to every nurse, but i wonder if the idea is aimed at the wrong people for a start. the question i will always throw at anyone is whether the line managers & trusts are willing to release staff to undergo such trainings. i have been working as a trained nurse for almost 3yrs and the problem i face is that managers and trusts appear to make sure they have staff on the ward and then worry about staff training later. i believe this is the reason why some mandatory trainings are done online when it might be better done as lecture. other managers try to use link nurses inappropriately in cascading information to fellow colleagues where its better to facilitate study days for all members of staff. other managers are very good and actually encourage each individual to attend study days. but for instance how do you justify 2 managers in same hospital setting offering 2 wks and 6 wks supernumerary training respectively within same hospital? i wiork in a very busy respiratory ward & look after terminal cancer patients, & end stage COPD but when you have no oncology ward within the hospital its not always possible to get patients to hospices in time. as a result i agree training is vital {but i am not sure about the idea of making it mandatory].

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  • Peter Goble, more power to you!!

    You are so correct, forget the ticky boxes - lets really raise the profile of ALL those dying in hospitals.

    The acute sector has rarely the time or the skills to provide the care that both the dying and their relatives deserve; sadly the acute sector does not appear genuinely interested in demonstrating genuine commitment to improving this provision - well, not until there are a few boxes to trick anyway!!

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  • Peter Goble - you've hit the nail.

    Lets get practical. Mandatory training is so big anyway that half the time the trainees are asleep!!! We need more of yous on the wards - sharing your expertise with staff hands on not in a room much away from practical experience. Why are we brushing everything with the same broom? Not all training is mandatory...this training is essential but practical and must be at the bedside!

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  • I am a registered Nurse working in a nursing home and we have been using the LCP for a couple of years and find it a very useful pathway to follow during the final days of life. We have had many words of thanks from relatives who have complimented on the quality of care we have given to their loved ones enabling them to have a dignified, 'pain-free' death, hopefully in the manner that they may have discussed in an advanced care plan. If people working in nursing homes are trying to access this training, they could contact their local PCT who will most likely be able to give them the information they reuire.

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  • Thanks Wendy,will surely do.

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