The mistakes of the past in the care of dying patients could be repeated if staff are forced to rely on formal processes rather than focusing on outcomes and informed judgment, warn researchers.
A study, by an expert in palliative care medicine from King’s College London, has assessed why the controversial Liverpool Care Pathway failed and recommended how hospital trusts might avoid similar pitfalls.
“Inadequate education and training meant they grasped onto the pathway as a kind of crutch rather than using it as the guide it was intended to be”
Dr Katherine Sleeman said the two key messages from her study – published in the journal BMJ Open – were a need to improve formal education and training in what is a “good death” and for a “reorientation away from processes to outcomes”.
Dr Sleeman’s research includes interviews with 25 NHS staff including 13 nurses as well as doctors and allied health professionals in 2009, prior to the outcry against the pathway and its subsequent abolition.
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The interviews were carried out as part of work to improve end of life care at King’s College Hospital NHS Foundation Trust, but have not been published until now.
Dr Sleeman said: “What this paper really highlights is that if people don’t know the fundamentals of how we care for the dying, whatever tool you give them it is unlikely to be used very well because no piece of paper can replace good clinical judgement.
“People really liked the LCP because it helped with processes – it made things clear and consistent,” she told Nursing Times’ sister title Health Service Journal.
“Those things benefit the healthcare professional,” she said. “What was interesting was that no one said they thought it benefitted patient deaths, suggesting the healthcare professionals who were using it were focused too much on processes and not enough on patient outcomes.
“This was particularly strong in more junior professionals, suggesting that inadequate education and training meant they grasped onto this as a kind of crutch rather than using it as the guide it was intended to be,” said Dr Sleeman.
“We need training in what is a good death, what does it mean for patients and what questions might we ask of patients”
She added that interviewees talked about receiving “piecemeal” education and training in palliative care.
“If people don’t have that comprehensive basis of education and training they’re unlikely to use any care pathway well, they are much more likely to rely on it as a protocol rather than a guide, and more likely to use it poorly,” she said.
Dr Sleeman said better education and training would help staff “move away from thinking they’ve done the right thing because they’ve prescribed morphine, towards thinking they’ve done the right because their patient had pain and now that pain is better”.
“We need training in what is a good death, what does it mean for patients and what questions might we ask of patients,” she said.
In May the health service ombudsman issued a report saying too many patients were dying in the NHS without dignity and the Care Quality Commission is currently reviewing the state of end of life care services across the NHS which is expected to be published later this year.
Trusts have also been tasked with formulating their own replacements for the LCP, after it was withdrawn following a critical review by Baroness Julia Neuberger in 2013 – itself prompted by a high-profile campaign against the LCP by families and the Daily Mail newspaper in 2012.
From the study: NHS staff comments on the LCP
“But it is documentation so it doesn’t do the care for you, … and there’s still an awful lot of thought and…work that you know needs to go into giving that care, … so it’s not a tick box exercise, … and I think there’s just a danger of that” – senior nurse
“The biggest challenge I find as a nurse is not really knowing where you stand sometimes with treatment with, you know, perhaps the weekend…that’s why I think the pathway is a good thing because it gives people guidance and gives us nurses something to follow” – senior nurse