The Liverpool Care Pathway: Does it improve the quality of dying?
The Liverpool Care Pathway (LCP) is an integrated care pathway developed in the late 1990’s (Ellershaw et al, 1997) as a means of transferring best practice in care of the dying, from the hospice environment to other sectors starting in the acute setting. Currently the LCP is a recognised tool used by clinicians in the United Kingdom as well as over twenty countries, to give appropriate care to patients who have reached the last hours or days of their lives. Described to provide comfort to the dying and also address the needs of the carers (Chapman 2009).
During this assignment the author will highlight and explain how a data search was conducted, and will analyse the data retrieved, explaining and evaluating the data to build a discussion based on the chosen topic of end of life care, with a focus on the Liverpool Care Pathway. The author will conclude by producing recommendations for practice.
Although described above that the Liverpool Care Pathway is an appropriate tool for providing adequate care for patients, it can also be seen as a controversial pathway, being described as a ‘tick box’ approach rather than a humanistic approach (Chapman 2010). It has been referred to by the UK’s Daily Telegraph as ‘sentenced to death on the National Health Service’ (Devlin 2009). The author has a keen interest in palliative care, after researching is interested in enhancing knowledge surrounding the LCP as there are many ethical debates surrounding the pathway despite being endorsed by the National Institute of Clinical Excellence (NICE 2004). Another reason the topic was seen as valuable is due to the Department of Health (2008) releasing the end of life strategy, showing that improving end of life care is increasingly regarded as a major national priority in the United Kingdom.
A computerised literature search was conducted combining Medline and CINAHL via EBCSO host (2011) to locate relevant articles to fit the question above. These operators were chosen as they are user friendly and supply a wide variety of relevant articles based on nursing. PICO framework was used to refine the chosen topic and help formulate the question based on the Liverpool Care Pathway (Schardt et al 2007).
The search was initially outlined as follows:
Problem – Quality of end of life care
Intervention – Liverpool Care Pathway
Comparison – No intervention
Outcome – Improved health care
PICO framework helped structure to a certain stage in my searching process but due to the nature of the research, and having no randomised controlled trials available it could not be taken further.
Inclusion criteria followed was to use qualitative methods to evaluate the LCP to gain doctors, nurses and relative’s opinions, also ensuring only articles that had ethical approval were located (Polit 2001). Research was requested from all countries as the LCP is not only used in the United Kingdom, so it was felt important to gain input from studies worldwide. Finally to ensure the articles were current, a limiter of between five to ten years old was added.
The search history only consisted of two relevant articles; the articles located are well references, one looking at the LCP from an international perspective and the other from a UK perspective. A wider search using the COCHRANE library (2011) was used to access their review on end of life pathways; this enabled the author to discover any recommendations based on all research conducted in the review. A final article was located using CINAHL again but in a more direct search using the articles title found when searching via Google Scholar (2004). This Italian article found will be used to recommend practice, as the research is not yet fully complete it can not aid discussion in this essay.
This literature review will analyse evidence and findings from four articles (Costantini et al 2011, Veerbeek at al 2008, Gambles at al 2006 and Chan 2011). The main outcomes that the articles focus on are, the effects the LCP has on the dying, and their families. Also the doctors and nurses perceptions on the LCP as a tool and the benefits it brings to their practice. Gambles at al (2006) is a qualitative study exploring hospice doctors and nurses perceptions of the impact of the LCP using semi – structured interviews of a purposive sample, undertaken in a 30 bed hospice in the North West of England. Standardised semi structured interviews can provide an appropriate way of exploring individual in-depth perspectives, offering logistical benefits (Polit 2006). Data was thematically analysed for emerging themes. The study recognises the guidance from the National Institute of Clinical Excellence (2004) as a mechanism for ensuring the needs of dying patients and their carers.
Veerbeck et al (2008) studied the effect of the LCP on the documentation of care, symptom burden and communication across three health care settings (hospital, nursing home and home care) in America, London and Singapore. The LCP was used for all patients for whom the dying phase had commenced looking at a group of patients before the pathway was commenced and whilst in process. Multi centred research is said to be more likely to produce generalisable, high quality results, which can promote the development of robust evidence for nursing practice (Kearney 2000). However limitations should be noted using this approach, that if communication between researchers is not regular and effective then the study may become problematic, differences in organisational culture and working practices can cause difficulty in carrying out a multi-centre study (Twycross at al 2007).
Veerbeck at al (2008) argues that after the introduction of the LCP, documentation had increased in all settings which included the hospital, nursing home and home care. Although the study recognises the need for ongoing education to ensure the documentation is comprehensive. Results in all aspects of documentation across 192 patients showed a dramatic increase in percentage from the initial study without the LCP in place. Although just because there is a visible increase in documentation, it does not necessarily mean actual care to the patient improved just that all the areas that are listed in the LCP to be documented have been. Gambles et al (2006) agrees as research highlights that the LCP facilitates appropriate documentation in all elements of the care pathway that are deemed important in the dying phase. Noting the regimented approach to documentation provides streamlining and therefore reduces the time spent writing but still ensures accuracy. Nurses also felt the documentation acted as a reminder as it was clear and precise, offering instructions where needed. This is important as it will be nurses who provide the primary care on the LCP (Murphy at al 2007). The study explains that saving time on documentation and giving the nurse confidence in planning could have a direct impact on the care that needs to be provided for both the patient and the relatives, therefore improving the quality of dying (Gambles at al 2006).
Symptom control was discussed, looking at the impact the LCP had on common symptoms in the dying process, which include; pain, agitation, respiratory tract secretions, nausea, vomiting and dyspnoea. With reference to confusion and lack of guidance that existed before the introduction of the LCP (Gambles et al 2006). The management of these symptoms was described as poor previous to the LCP, that being said it was accepted that these symptoms were unavoidable in dying patients (Jack at al 2003). Jack et al (2003) interviewed nurses in an acute hospital who reported that symptom control was poor pre LCP, but evidence in the study from nurse opinions suggested that there had been an improvement in the management of chest secretions and terminal agitation once the LCP was in situ. However since the introduction of the LCP there is a consensus of opinion between nurses that there has been an improvement in symptom control, giving clinicians more confidence in their practice, for example junior doctors have more confidence in prescribing pain relief in the later stages of life (Gambles et al 2006). This may be due to the LCP providing a clear outline for what is expected, in regards to symptom relief including goals for four hourly comfort measures, medications, treatments and procedures. In addition to this ‘as required’ subcutaneous medications are written up as per protocols, covering the common symptoms mentioned above. In this way anticipatory prescribing ensures there is no delay in responding to the patients requirements and improving patient comfort. Having guidelines, protocols and common symptoms outlined within the LCP gives doctors an evidence base and possibly more confidence in prescribing (Preston 2007).
Veerbeck (2008) addresses symptom burdens and again agrees with the research conducted by Gambles at al (2006) that since the LCP has been implemented symptom burdens have decreased. This is an important factor to address as symptom control has often been characterised as a key concern in end of life care (Plonk 2005). Veerbeck’s (2008) study states the decrease was noted by both the nurses in their assessments and the relatives looking at patient comfort. Although validity of this must be questioned as nurses may have been inclined to give more positive ratings, and due to the study not being blinded, this could result in an overestimation of the effects of the LCP. However nurses could have given a more realistic account of the symptoms as they should be more alert to signs the patient’s show due to their training and understanding of what is expected in the last stages of life, which may have resulted in an underestimation of the effects of the LCP. When looking at the study the baseline refers to the period in which the LCP was not in situ, the intervention period shows when the LCP was implemented. The relatives were only involved in the baseline or the intervention period, so effectively they were blind to the process and could not make a comparison unlike the nursing staff who were involved throughout the whole study both baseline and intervention. Therefore the relatives were not aware of the changes in care methods. Once the opinions of the relatives were collected and evaluated, the baseline and intervention opinions were compared. Research findings suggest that relatives rated patient symptoms more positively during the LCP intervention period. This suggests that using the LCP contributes to a decrease in symptoms for dying patients, thus improving quality of death.
Even though the two studies discussed (Veerbeck 2008, Gambles 2006) agree, this is only based on relatives and clinicians opinions. Only the patients themselves would be able to provide an accurate account of their own feelings and symptoms which questions the reliability of the research (Chan 2011).
Communication between the dying patient, his or her family and professional caregivers is also regarded as a crucial aspect of care for the dying (Hanson et al 1997). Veerbeck (2008) states relatives showed appreciation of communication received in the LCP phase of the research. Although it should be recognised that the institutions that participated in the research study were specifically interested in providing high quality palliative care to dying patients. Which would suggest that communication skills may have been good quality before the LCP was implemented in the baseline stage. Although there is no reference during the study which refers to training or audits regarding communication so this is not possible to measure. Furthermore there is no evidence to suggest how communication was received by the patient (Chan 2011).
Gambles et al (2006) clarifies the importance of communication in the primary care team being prioritised within the LCP, impacting positively on the relationship between the staff and the families/patients. The LCP provides prompts to initiate difficult conversations with both the patients and families. Although during research a doctor suggested that the communication is a factor which is affected by the expertise of the professional delivering the care, not solely from the LCP’s guidance. Use of the LCP is not meant to replace clinical judgement and decision making (Murphy 2007).
However other care professionals view the guidance of the LCP of benefit with relatives in order to explain the level of care involved (Gambles at al 2006). Again it could be argued that health professionals should not need a care pathway to follow to provide good communication skills to patients, relatives and colleagues, even in difficult situations (Brooker 2003) as practice should be up to date, tested by clinical audits and continueal professional development (NMC 2008), (Brooker 2003).
Gambles et al (2006) acknowledges the potential for using the LCP as a teaching and education tool, to aid development of staff and therefore potentially improve quality of dying for the patients. Thus because the clinicians would be up to date in their delivery of care in regards to the LC P and importantly practicing within evidence base research. Participants in the study recognised consistency as a valuable asset that should be offered by all clinicians, especially nursing staff who deliver the LCP on a ‘front line’ basis. Consistency can be further promoted by the use of the LCP as a teaching tool for students or newly qualified within the palliative setting. A negative noted during Gambles et al (2006) research is that not all staff delivering the LCP felt they have received adequate training to effectively deliver the pathway even though it is described as a simplistic tool it is in a sensitive field and if not delivered properly may affect the delivery of care. Therefore it may possibly affect the patients or family’s experience of death. Although clinicians should ensure they maintain continuous professional development, where any training needs or concerns should be highlighted (NMC 2010). None of the other studies looked at during the assignment acknowledged or recommended training as an important factor, but the author feels it should be an important factor. As nurses we should ensure we act in patient’s best interests. Ensuring we practice using up to date evidence based care (Nursing and Midwifery Council 2008).
Although there appeared to be initial scepticism regarding the value of the LCP during Gambles et al (2006) the opinion amongst the doctors and nurses was that the LCP is a valuable tool in the delivery of care for the dying, stating they do feel it contributes along with holistic care to improving the quality of death. Feelings were expressed stating the pathway is not only a science, as it does not take away and skill or clinical judgement as a clinician. It offers structure and prompts where required. The findings in the study show the LCP is a valued, comprehensive, logical template which impacts positively in the hospice. It was also noted that the tool made it easy to contact all members of the multi-disciplinary team that are involved in the patients care, which has the potential to improve the continuity of care for both patients and relatives.
However although it was recognised that the LCP could promote consistent delivery of good care, it requires appropriate teaching and regular education to ensure that the LCP document has been used appropriately, requiring critical appraisal of the care delivered from the LCP (Gambles et al 2006).
Limitations of the Gambles et al (2006) study should be recognised, as although thoughts and experiences of the LCP were positive from both doctors and nurses, the data was collected from a relatively small sample in one hospice. This does not provide a wide variety of opinion from a range of sectors, having a larger more varied sample would improve validity (Cutcliffe et al 2003). The sample consisted of a range of nursing grades, but mainly of sister or management level. The results may have been different if the staff interviewed were newly qualified and possibly had less knowledge of the LCP.
Veerbeck (2008) concludes that the LCP contributes to the quality of documentation and symptom management in the last stages of life, both factors add to the improvement in care. Veerbeck et al (2008) considers the use of the LCP beneficial for the care of patients and families. Again limitations of the study should be recognised. The study across the different areas such as nursing home and hospital used the LCP for different lengths of time. For example LCP care was provided for 3 days in the nursing home and in care provided at home, but only 16 hours in the hospital environment. Therefore results particularly on symptoms may vary, due to symptoms worsening in later stages/hours. However the proxy measurements have been shown to be relatively valid for such objective variables (Klinkenberg 2003).
Although the LCP has been disseminated nationally as part of the End of Life Care Initiative to improve care for dying patients in the United Kingdom (Ellershaw 2005b), its possible benefits have not been evaluated scientifically so far. It is accepted that conducting trials involving the dying is challenging due to ethical issues, including difficulty in recruiting patients as they may be too ill or unable to provide informed consent. However researchers should attempt to investigate LCP interventions with rigorous research methodology (Fowell 2004). Randomised controlled trials are needed for the evaluation of the use of the LCP in caring for dying people. In future studies, outcome measures should include reviews in relation to patients (Chan 2011). Chan (2011) explains that due to the lack of evidence, they can not make recommendations for the use of the LCP in caring for the dying at present time. Although until there is evidence indicating harm caused by end of life pathways, there use may be continued.
In view of the need for a randomised controlled trial to build an evidence base for the LCP, Costantini et al (2011) has launched a 3 year research programme to assess the LCP in four Italian hospitals. The aim of the study is to discuss and critically evaluate the effectiveness of the LCP including a patient’s perspective. Although the results of the study are not yet available, on completion of the research it may be possible to use the findings to support the LCP further.
During the study conducted by Gambles et al (2006) the importance of education was mentioned as a key factor to ensuring the delivery of the LCP is successful. Another recommendation would be to offer regular training and education for staff to discuss concerns and as a way of critically appraising the delivery of care. In agreement to this as a recommendation, Taylor (2005) suggests without robust implementation and education strategy the LCP could be at risk of becoming a series of tick boxes. It is crucial that the health professional understands the background and principles of palliative care in order to use the LCP document to the full potential.
In conclusion the challenges to the LCP remain concerning, and the LCP alone may not be the answer to solve all the issues surrounding end of life care. However with the evidence presented and the potential results from Costantini et al (2011) it may be able to aid best practice in care of the dying, providing a framework to develop and guide practice (Taylor 2005).