HOW WAS THE LCP DESIGNED?

 

Development of the LCP

Developing an ICP to guide the delivery of palliative care in its entirety is fraught with challenge because of the inherent complexity and wide-ranging nature of this specialty. Increasingly, the principles of good palliative care are seen as being important from the point of initial diagnosis of advancing disease to death. It would have been unrealistic to attempt to establish a pathway of care that could meet the needs of all patients throughout such a complex and protracted care trajectory. It was, therefore, vital to identify an important, yet discrete and time-bound element of palliative care that could be successfully mapped. To this end, in the late 1990's the Hospital Specialist Palliative Care Team (HSPCT) at the Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) together with staff from the Marie Curie Hospice in Liverpool identified Integrated Care Pathways as a way to improve care for dying patients and their families.

 

Although the hospice and hospital environments were clearly very different, it was felt that the development of an ICP to translate the hospice model of best practice in care for the dying into a template of care for use by ward staff in the acute setting would empower generalist workers and improve care for patients and families. By enabling ward staff to manage the majority of expected deaths appropriately, it would also allow the HSPCT to concentrate its efforts into supporting patients and families with more complex specialist need.

 

With the support of Sue Overill who was the Integrated Care Pathways Co-ordinator at the RLUHT, the HSPCT devised a care pathway for the dying phase.

 

We believed that if we collaborated with our generic colleagues on essential elements of care in a progressive timeline within a pathway format, the HSPCT could successfully educate staff to take charge of their patients in a way, which will meet the needs of the patient and carer and staff.

 

We believed that the care of the dying had been regarded as specialist practice but that if we introduced a care pathway for the last days of life we could support the ward teams to manage this episode of care in the generic area and we could impact on the care of patients whom we would never meet.

 

A major cultural shift is required if the needs of dying people are to be met and the workforce is to be empowered to take a leading role in this process. Dying patients are an integral part of the population of general hospitals. Their death must not be considered a failure; the only failure is if a person's death is not as restful and dignified as possible. Often the complexity of the measurement of palliative care intervention has thwarted effective outcome measures being developed. We believe the Liverpool Care Pathway for the Dying has the ability to change practice promote multiprofessional collaboration and articulates evidence based practice.

 

The imperative for the project was to translate the excellent model of hospice care at the end of life into the acute arena and develop outcome measures for end of life care using an integrated care pathway.

 

 We developed a cycle for learning and improvement with 4 key questions:

1. What are we trying to accomplish?

2. How will this impact on the patients we will never meet?

3. How will this impact on our service?

4. How will we measure success?

 

At that time the programme was led by John Ellershaw - Medical Director / Marie Curie Centre Liverpool (MCCL) / Consultant - The Royal Liverpool and BroadgreenUniversity Hospitals Trust (RLBUHT) Specialist Palliative Care Team (HSPCT) and Deborah Murphy - Directorate Manager HSPCT, RLBUHT and was supported by a steering group comprising input from other members of the HSPCT at the University Hospital. A multidisciplinary working party made up of those professionals representing elements of care felt to be important in the dying phase was set up. Included were representatives from nursing, palliative medicine, social work, pastoral care, pharmacy, members of the pilot ward team and an integrated care pathways co-ordinator. It was important that the group also included representation from Senior Management within the Trust to ensure executive endorsement of the project