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"Pathway to death?"

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Ed Lumley

on 8 October 2013

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Transcript of "Pathway to death?"

The LCP
Jess Hemingway & Ed Lumley
"Pathway to death?"
#4 Communication
In the News
Norman Lamb
15th October 2012
Outline
1. What is the LCP?
2. "Read all about it!"
3. Timeline of articles
4. Key concerns:




8. Conclusion
14th October 2012
Liverpool Care Pathway
Developed at the Liverpool and Broadgreen Royal Hospitals 1990's

To improve care of the dying in the last hours/ days of life

A complex intervention for the mutual decision making and organisation of care given to those in their last hours or days of life
AIM:
LCP:
WHAT:
a) Consent?
b) Predicting end of life
c) Financial incentives
d) Communication
‘However, as we have seen, there have been too many cases where patients were put on the pathway without a proper explanation or their families being involved. This is simply unacceptable.’
MP Norman Lamb
Readily available
Information
Powerlessness
Vulnerability
}


MDT approach
Advance planning
SMART goals
Regular contact
Determine whether any further medications and tests would be helpful

Maximise patient comfort

Decide whether artificial fluids should be given, when a patient has stopped being able to eat or drink

Whole patient care i.e. cater for patient’s spiritual or religious needs
1)


2)

3)



4)
1) Patients being subjected to invasive
testing and treatment that offered
no chance of preventing death

2) Causing unnecessary pain and
suffering by needlessly prolonging
life
1990's
#1 Consent
#2 Can we predict
end of life?
#3 Financial intensives for LCP
#4 Communication
#2 Predicting end-of-life
#1 Consent
Caregiver does NOT have to obtain legal consent

But must be acting in PATIENT'S BEST INTEREST

Consent of relatives is not required, however they should be informed.



If views conflict with medical decision:
2nd opinion
Court of protection
There should NEVER be an occasion when a relative or carer who is named as the main contact is not informed when a diagnosis that the person is dying has been made
“Uncertainty is an integral part of dying. There are occasions when a patient who is thought to be dying lives longer than expected and vice versa. A second opinion or the support of a palliative care team may be required”
Autonomy : Confidentiality : Capacity
#3 Financial Incentives
financial incentives for LCP since 2009
Conclusions
Communication is the Key!
Timeline
450k deaths in NHS per year
180k deaths on LCP

=29% of NHS deaths
29%
71%
LCP
non-LCP
Factors deciding LCP initiation:
Pressure on beds
Difficulty with nursing
Confused patients
Difficult-to-manage elderly patients

"Financial incentives for such high risk decisions is
dangerous"

"It an assisted death pathway rather than
a care pathway"
Prof. Patrick Pullacino
A patient can be taken off the LCP at any time!

Palliative care physicians should be involved at an early stage to facilitate appropriate diagnosis, prognosis and communication to the patients
'Given the fact that the diagnosis of impending death is such a subjective one, putting a financial incentive into the mix is really not a good idea and it could sway the decision-making process.'
£30m
£308k
for a trust that met annual LCP targets
LCP is designed to make patients feel comfortable during their final hours/days of life

It requires MDT input

Communication is essential to its success

It is an emotive and politically charged topic that warrants sensitivity, compassion and careful consideration.
Who?
Payments made by the "Commissioning for Quality and Innovation” (CQUIN)
Anyone who is within 2 days or hours of dying.






Can assess all patients nearing the end of their life with the "Holistic Common Assessment"


Instead of treating the underlying patholgy with the aim of halting disease progression, care is focussed on comfort and symptom control.

Symptomatic treatment of:
Pain
Agitation
Respiratory tract secretions
N&V
SOB
Background information and assessment
Preferences
Physical needs
Social and occupational needs
Psychological well-being
Spiritual well-being and life goals
Aims
Individual case management
Capacity
Spiritual Needs & Expectations
Uncertainity of death
Hope
Prognosis
Communication
Best Interests
Reporting bias
Full transcript