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 www.mcpcil.org.uk).
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
● To improve the knowledge related to the process of dying
● To improve the quality of care in the last hours or days of life
● Initial assessment
● Ongoing assessment
● Care after death
Key domains of care
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