Nurse-led services protect patients from the “idiosyncrasies of the individual clinician” and should be championed and not attacked.
The demand from a nursing leader comes in the wake of criticism levelled at one of the most widely used protocols for the care of the dying by a group led by University of London’s emeritus professor of geriatrics Peter Millard.
Professor Millard said terminally ill patients are dying prematurely as a result of the guidelines, known as the Liverpool Care Pathway for the Dying Patient (LCP).
He criticised the pathway’s protocol based approach, describing it as “tick box” medicine and saying that guidelines cannot be “followed blindly” to get results.
He told Nursing Times this week that nurses should not be taking the decision to change treatment, and thatguidelines should not be followed “slavishly”.
“Nurses should not be making decisions it is beyond their experience and qualifications to make. You need to have
people who know medicine making decisions on treatment or you run the risk of poor decisions being made.
“I don’t think nurses have had the training to make decisions on prognosis or diagnosis.”
However, Queen’s Nursing Institute director Rosemary Cook told Nursing Times that adopting a protocol based
approach to care is about being more open about the nursing care that patients receive.
“Protocol-led care has vastly improved the lot of the patient, with clearly defined treatment pathways meaning that care is not left to the idiosyncrasies of the individual clinician,” she said.
“It is not just an ordinary nurse with a ‘tick sheet’, nurses leading services are highly experienced and highly qualified. They have a high level of clinical and academic development and have to be very overt about the service
Marie Curie Cancer Care’s director of nursing and patient services Susan Munroe defended the LCP.
“It is too simplistic to say the LCP is just about ticking boxes. It is a guide to prompt thinking about what pain
relieving drugs or anti-emetics should be being used, and by no means is it a ‘must do’ tool,” she said.
The LCP, developed by the Marie Curie hospital in Liverpool, adopts a multidisciplinary approach to
end of life care. Originally designed for use in hospices, it has now been adapted for use in a variety of clinical settings for all patients requiring end of life care.
The protocol driven pathway guides healthcare professionals on how to ensure that patients are kept comfortable when they reach the end of their lives.
It provides guidance controlling symptoms, knowing when to prescribe certain drugs to prevent symptoms before they start, and when to discontinue treatments or aspects of care.
The decision on which patients are put on the pathway is taken by the multidisciplinary team, but once a patient is on the pathway much of their care will be undertaken by nurses using the LCP as a guide.
A Department of Health spokesman said the LCP was an “established and recommended tool”.
However, Ms Cook said the case for nurse-led services must be strengthened by development of a stronger evidence base.
She told Nursing Times the best way for nurses to silence their critics is by demonstrating how their services have improved patient care.
“Nurses have had to fight to lead services and are expected to answer more questions and be more open than if a doctor is setting up a service,” said Ms Cook.
“But they have to be able to demonstrate that the service is improving patient care and clinical outcomes. The QNI spend a lot of time working with nurses on how to set up services and showing them how to demonstrate measurable outcomes.
“All healthcare professionals need to be more comfortable with measuring and auditing services to demonstrate
outcomes. If they cannot do this, the service should be questioned.”
Professor Millard is not the first member of the medical profession to criticise nurse-led services. Last September, Leicester GP Dr Rhona Knight said nurses should not be allowed to lead primary care services, arguing that it “devalues medical training and GP expertise”.