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'End-of-life talk must never be just a target'


When the Liverpool Care Pathway was replaced by Priorities of Care earlier this year, it was intended to ensure that health professionals approached conversations about dying sensitively.

The change resulted from a media backlash against the LCP, which cited cases where it had been used insensitively or incorrectly. Distressed families saw the pathway as a tick-box exercise started with little or no consultation with the patient or family, and used without compassion.

Many experts supported the LCP, arguing that the problem was not with the pathway, but the way in which it was being implemented by clinicians who had received no or inadequate training around talking about dying. They may have been right.

Our story on page 3 reveals shocking accounts of community nurses asking vulnerable older people about end-of-life decisions in a way that is frightening rather than involving and supportive.

Any system to discuss dying is only as good as the people who carry it out. If their training is poor and they are neither confident nor competent in this, patients are almost certain to be distressed.

Chief nursing officer for England Jane Cummings has promised to review a questionnaire that prompts nurses to ask questions of dying patients in a “blunt and impersonal way”. But it may be more than the questionnaire that needs reviewing.

The news that some community nurses have been phoning patients out of the blue to discuss their wishes around resuscitation is shocking. This is not a subject to be brought up without warning or reason - particularly when the nurse cannot see patients, gauge their reaction or read their body language.

There is one chance to get this right. Nurses don’t want to do this badly, they want to do it well, organically and holistically. Nurses do not need to be put into a position where finding out about how a patient wants to be treated if they have a serious condition becomes just a part of hitting another target.

Have we really learnt nothing from Francis? What nurses need is training and support as they develop confidence and experience in this difficult area. And, most importantly, they need enough time to be able to talk about death compassionately and in a way that feels natural and appropriate to patients. They want to be able to do it right.

Jenni Middleton,editor

Follow me on Twitter @nursingtimesed


Readers' comments (5)

  • Will never forget watching a home health nurse and conservator tried to convince elderly friend to sign DNR. This gentleman had a medical background, and went through a very clear, precise, and logical list of what steps he did and didn't want (feeding tube - give it a try, see if it helps, CPR yes, breathing machines no, heroic measures no, etc..).
    It was disturbing to watch both the nurse and conservator try to cajole, plead, and frighten him into signing a DNR despite his clear, polite (and repeated) refusal.

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  • End of Life care facilitators educate and support the generic workforce to have conversations with people about advance care planning, however they are trying to support a workforce that are already overstretched working in a task orientated way, who are frightened to broach the subject of choices around end of life because of the time it may take to fully engage in a sensitive conversation. We need to allocate appropriate time to this activity as doing it with compassion and care can make a difference to people with end of life care needs and their families. We are here to walk alongside people on this journey and enable them to make the choices, even if these choices do not fit in with any set targets set as a cost saving initiative

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  • Charlotte Peters Rock

    It would be interesting to know just how it is presumed that the 'Liverpool Care Pathway' has been superseded by the new (and also obviously still unworking) method.

    A large number of people across this country are still struggling with the damage deliberately done under LCP - in my and my sister's case more than 10 years ago, and still unresolved. So no-one should be pretending that LCP has 'gone'. It hasn't. Its terrible damage, needs to be unpicked and humanely dealt with.

    My father, Ralph Winstanley, for instance, had not been dying, but was deliberately killed, using the NHS and its untried, untrained LCP staff. Yes we have full documentation to clearly show that is the case. Being in South Yorkshire, the person who can clearly be shown to have been in control of that killing, has neither been investigated nor prosecuted.

    The editorial lines and comments above, clearly show that yet again the only way to describe the new approach is 'cack-handed'.

    We deserve better than this.

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  • I don't a think a pathway is to blame. End of life requires nurses and doctors to be suitably trained for the support and the difficult conversations. Often communication is the core of complaints and misunderstanding. Advanced directives to ensure everyone has treatment they want before entering into the hospital.

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  • Charlotte, U r not alone-thousands were killed on LCP. probably not intentionally and nurses do need training in palliative care, even if patients REALLY are dying. Even Doctors need better skills in prescribing in these cases. Please publish your comments on twitter and everywhere u can. Hope u get justice done for your father.

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