Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Nurse-led services protect public from medics’ quirks


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”.


Readers' comments (8)

  • Professor Millard can't be unaware that the LCP was developed by an experienced palliative care consultant, John Ellershaw, who has seen it in action and refined it (with his nurse colleague Deborah Murphy) to be a working tool which actually answers the needs of those at the end of life.
    Being a professor does not protect you from talking tosh. It seems that he has deliberately blinded himself to the most obvious benefits of the protocol approach: consistency in planning; raising all care to the level of the best. The LCP has proved its worth, and it sounds as if Prof Millard wants to deny his own patients the benefit of it, in favour of ... what? An inconsistent approach? Let's see your evidence, sir, and not just your grumpy opinion.

    Andrew Makin
    Nursing Director
    registered Nursing Home Association

    Unsuitable or offensive? Report this comment

  • Beyond our experience and qualifications?

    This man may be a professor but he clearly doesn't have much intelligent thought behind what he says.

    Is he aware of exactly how much a nurse does now? Of exactly how qualified some of us are now (as much as if not more than a doctor in some cases)? Or even how far up the proverbial creek doctors would be without our qualifications and skills?

    I think it is about time idiots like this are drummed out of the profession and nurses are given the respect, status and pay we deserve.

    Unsuitable or offensive? Report this comment

  • I am not a nurse, but the comments of the professor and of the people who have responded here speak volumes about how nurses feel treated by, and about the arrogance of, the medical establishment.

    @Anon - I do not think that you were deviating at all. I, for one, am not suprised that you recieved no help in training and learning from GPs. Anyone who has been unfortunate enough to visit A GP recently will appreciate that such things are beneath them. In fact one feels that patients, coleagues etc just get in their way somehow. It would be better for them if they did not have to bother with all that nonsense and then they could get straight to the golf course. This would be mildly acceptable if they actually got things right. In the last two years my local set of GPs has failed to diagnose my Lyme disease, a winged scapula, my son's broken collar bone etc.

    I would say to Professor Millard examine the plank in your own eye before you start and remove the splinter from mine.

    Notice that we all put in comments in anon as well - what does that tell you. For God's sake don't criticise a doctor, let alone a professor.

    Unsuitable or offensive? Report this comment

  • As more people choose to die at home, does professor Millard think that GP's will have time to review these palliative patients daily or respond quickly when the need arises. I fear the answer is NO. End of life care needs appropriate structures in place dedicated to this care delivery. I feel the professor is too far removed from the front line to understand this.

    Unsuitable or offensive? Report this comment

  • The LCP is flawed and dangerous and was never intended to be a diagnostic tool to determine whether someone is terminally ill; simply a pathway to follow after diagnosis (i.e in advanced terminal cancer cases). Old Age is NOT a terminal illness, but in applying the LCP it is being treated as one, and families are being left devastated as a result of this.

    Unsuitable or offensive? Report this comment

  • michael stone

    Anonymous | 15-Jun-2011 12:58 pm

    I had a very bad experience when my mum died at home a couple of years ago, not related to her care (fine) but to the way I was treated when 999 became inappropriately involved. Since then, I have been discussing EoLC with many people and bodies, and trying to get EoLC to look sensible if you are a patient or a relative, especially for deaths at home.

    Dying, is NOT 'something for clinicians to control'. It should be up to PATIENTS to decide how they wish to die - at home or in hospital, in pain and alert or sedated and out of it - etc. Doctors and nurses, should be FACILITATING the wishes of the dying patient !

    And, not only is 'tick box' potentially dangerous, but get this straight. If staff are indeed highly trained, they should be able to adopt principles-based behaviour. If staff are not sufficiently competent to employ their own expertise and principles, then they need 'tick box rules to follow'. MIXING THE TWO leads to nightmares !

    I don't like 'Pathway', because it implies pre-determination. Dying should happen as the patient wishes, and it cannot be pre-determined. It should be like driving from London to Liverpool, and determining the best route as you drive - not sticking to a pre-planned route, despite unexpected traffic jams and roadworks. And the patient should be the driver !

    Just pay more attention to what patients want, and drop this 'we know best, and make decisions about you' attitude !

    I'm getting irrate, as this winds me up no end, so I'll stop at this point !

    Unsuitable or offensive? Report this comment

  • michael stone

    I sent this article to a contact of mine, as an aside, but the resulting e-mail exchange does draw out the fundamental issue about ‘tick-box’ behaviour:

    Me: Someone has just had a go at the LCP (piece appended).
    I suspect that although I have concerns about the LCP, my own do not mirror his - but I'm strongly with anyone who writes this:
    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.
    If you claim that people are highly-trained, then you should have
    principles-based behaviour: tick-boxes are for people who could not otherwise make the correct decisions. Mixing 'principles and competent' with 'less competent and needing tick-box rules to follow' becomes nightmarish ! But I'm not claiming to have a complete answer to that one !

    Her: He's right and wrong. a) protocols are not substitutes for professional
    judgement and b) the LCP is not a tick-box.

    Me: Yes, but do all nurses understand both a) and b) ? And the LCP is about
    dying - it should be up to patients to decide how they want to die, and
    for clinicians to try and facilitate those choices (while within the law):
    that is definitely something nurses, in particular, have problems with,
    because many nurses do what doctors tell them to, not what patients tell them to do.

    Her: But you don't rectify any of that by attacking the LCP. Rather, you argue
    for proper training of staff and proper facilitation of the LCP.
    Training and guidance are both intended to ‘create the best behaviour’, but guidance can be either ‘the objective should be ‘X’, and these are the ‘principles’ involved’, OR ‘if ‘Y’ then you should follow this list of rules’.
    The problems, hinge on the fact that no list of rules, can cover ‘the edges of the distribution curve’ AND ALSO be short and clear enough, but leaving people to ‘make their own choices’ requires a much higher level of individual competence.
    It is compounded, by the fact that if you apply ‘rules’ which work for the majority of situations, to those ‘unlikely situations the rule-writer ignored’, then following the rules often makes the situation worse, not better.

    Unsuitable or offensive? Report this comment

  • michael stone

    That did not post as I typed it - the email discussion ends at 'and proper facilitation of the LCP' - the bit after that, is my own added explanation of the problem.

    Unsuitable or offensive? Report this comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.