The Liverpool Care Pathway for the Dying Patient (LCP) in New Zealand

The Liverpool-based pathway steering group included specialist palliative care nurses, a consultant in palliative medicine, an integrated care pathway coordinator and development officer, a representative from the pastoral care team, a pharmacist and members of the hospital ward team. The premise of their work was to prevent unnecessary suffering in the last days and hours of life because of a lack of recognition of dying and delivery of timely and appropriate care.[2],[4] The steering group identified key outcomes and goals of care from book reviews, specialist journal searches, abstracts from conferences, reviews of patients notes, and the clinical experiences and expertise of staff.[3],[4] The resultant evidence-based, integrated care pathway for the last days and hours of life was named the Liverpool Care Pathway for the Dying Patient (LCP).

As with any quality improvement tool, the LCP document has undergone continuous review since its inception, with Version 12 the newest document. LCP Version 12 has greater clarity than its predecessors in key areas, particularly communication, nutrition and hydration. There are twelve 'goals of care' that encompass physical, psychological, social, spiritual, religious, and cultural aspects of the care of the dying across three sections – an initial assessment, ongoing care and assessment, and care after death.

A patient must not be commenced on the LCP unless the multidisciplinary team caring for that person agrees that the person is in the last days or hours of life. Diagnosing dying is difficult and complex. This is not a decision to be made in isolation.There will always be occasions when, although the team has agreed that the patient is in the last days or hours of their life, the person's condition inexplicably improves and they go on to live a long life. Alternatively, they may deteriorate again in the coming days, weeks or months. Commencing a person on the LCP does not mean they have to die. If there is improvement in the person's level of consciousness, functional ability, oral intake, mobility or ability to self-care, and/or the patient, relative or carer, or a team member expresses concerns regarding the plan of care, and/or it has been three full days since the LCP was commenced – a full team re-assessment is required to ascertain if the plan of care needs to change direction and the LCP discontinued. As with all clinical guidelines and pathways, the LCP aims to support, but does not replace, clinical judgment. The LCP is only as good as those using it. Implementing the LCP must be underpinned by a robust education and training programme.

The initial assessment makes explicit the individual plan of care at the time the patient is commenced on the LCP. Anticipatory prescribing of appropriate 'as required' medications to prevent delays in managing the five most commonly occurring symptoms at the end-of-life - pain, agitation or restlessness, nausea or vomiting, respiratory tract secretions, and dyspnoea - is a part of the LCP initial assessment. Prescribing is guided by locally developed algorithms that reflect specialist palliative care best practice. Again, assessment is the key with health professionals prompted to first consider non-pharmacological interventions. For example, when assessing agitation or restlessness, the LCP prompts the health professional to exclude pain, urinary retention and to consider spiritual distress as potential causes before considering sedative medication to manage this symptom.

The LCP requires healthcare providers to undertake an initial assessment of every aspect of care against an outcome. Ongoing review of each aspect of care is then prompted every four hours until death. As an example, Goal 7 in Version 12's 'initial assessment' states: The need for clinically assisted (artificial) hydration is reviewed by the multidisciplinary team. The goal is qualified by a prompt stating patients should be supported to take fluids by mouth for as long as tolerated. The goal is achieved when the team has reviewed the need for the use of clinically assisted (artificial) hydration, the outcome is clearly communicated (not required; discontinued; continued; commenced) with the patient (where possible) and with the relative or carer, and the decision documented on the LCP. A variance is recorded when the team has not reviewed the need for use of clinically assisted (artificial) hydration. The variance sheet tells the patient's individual story. Variance provides other clinicians in the environment with a clear picture regarding the choices made and the care delivered.

The pathway demands the healthcare professional regularly assesses every four hours that: "The patient receives fluids to support their individual need." The expectations of the goal relate to whether the patient is supported to take oral fluids/thickened fluids for as long as is tolerated and that the plan of care has been explained to the patient (where possible) and/or carer. The reason(s) for any variance must be then documented on the variance sheet.

This aide memoir checklist for ensuring that every aspect of care is considered and re-assessed regularly has been unfairly criticised as a 'tick-box' approach to care of the dying. It is in fact a robust plan of care that facilitates regular assessment, delivery, review and documentation of individualised, best practice care. The LCP provides a clear and auditable record of each patient's journey toward death, as well as the care afforded the deceased/tūpāpaku and family/whānau after death.

The stellar rise of the LCP as a new innovation for improving the care of dying patients and their families/whānau has captured the attention of the palliative care world. New Zealand is one of 18 countries worldwide to have registered to use the LCP and is the first country in the world to be supported by the LCP Central Team in the United Kingdom to develop a national office to coordinate the sustainable implementation of the LCP in its own country. The National LCP Office New Zealand[5] was subsequently established in November 2008 and is funded by the Ministry of Health.

The 2001 New Zealand Palliative Care Strategy[6] is the first strategy of its kind in New Zealand and is widely acknowledged as the foundation document for the development of palliative care services nationally. The vision of the strategy is that all people who are dying and their family/whānau who could benefit from palliative care have timely access to quality palliative care services that are culturally appropriate and are provided in a coordinated way. The strategy also prompted a review of New Zealand's Specialist Palliative Care Service Specifications (NZSPCSS). The Draft NZSPCSS[7] is currently being finalised at the Ministry of Health. One of the seven specifications is for District Health Boards to implement a 'last days of life care programme' for people in whom death is expected within days rather than weeks, regardless of setting. This recognises that dedicated systematic approaches and pathways have a key role in improving end of life care in New Zealand. The LCP has been used in New Zealand since 2004, with 236 registered LCP sites to date.

In June 2009, then Health and Disability Commissioner, Mr Ron Paterson, commented that the LCP promotes every consumer's right to be treated with respect and to be provided with services that take into account the needs, values, and beliefs of different cultural, religious, social and ethnic groups, including the needs, values, and beliefs of Maori. Mr Paterson believed the LCP promotes the delivery of care in a manner consistent with the person's needs, minimises the potential harm to, and optimises the quality of life of, that person while encouraging cooperation among providers to ensure quality and continuity of services.

In contrast to the criticisms that have surfaced over the past six months, the LCP clearly does not sanction euthanasia and does not mandate any unethical actions such as continuous terminal sedation or withholding of food or fluids. What the LCP does do is enable the sharing of evidence-based, best practice care of the dying whilst supporting healthcare professionals to deliver the quality care they aspire to provide, irrespective of care setting. In the immortal words of Dame Cecily Saunders, all the careful details of the pathway are a salute to the enduring worth of an individual life.[4]

Theresa Mackenzie RN MN is National Liverpool Care Pathway Lead New Zealand

References

1. Kelsey, S. (2005). Managing patient care: Are pathways working? Practice Development in Health Care, 4(1), 50-56.
2. Ellershaw, J. E. (2007). Care of the dying: What a difference an LCP makes! Palliative Medicine, 21, 365-368.
3. Ellershaw, J. E., & Ward, C. (2003). Care of the dying patient: The last hours and days of life. British Medical Journal, 326, 30-34.
4. Ellershaw, J. E., & Wilkinson, S. (2003). Care of the dying. A pathway to excellence. Oxford: Oxford University Press.
5. http://www.lcpnz.org.nz/pages/home/
6. Minister of Health. (2001). The New Zealand Palliative Care Strategy. Wellington: Ministry of Health.
7. Palliative Care Cancer Treatment Working Party Subgroup. (February, 2008). Draft New Zealand Specialist Palliative Care Tier Two Service Specifications. Authors.