Liverpool Care Pathway - Essay Example

?Liverpool Care Pathway Introduction Over the past twenty years since its implementation, the Liverpool Care Pathway (LCP) for the dying has become one of the most disputed management of care in the modern times. As such, there has been an increased interest in the media and public discussions which have undoubtedly raised serious questions about its efficacy in providing high quality care for the dying patient. Various sources have argued that, the care pathway has presented a meansof killing terminally ill patients premature by withholding and withdrawing food and water and that it has become an equivalent of euthanasia for the elderly (British Medical Journal, 2013), such as the recent scandal concerning the Mid Staffordshire hospital. On the contrary, other sources including that of the Health Minister Jeremy Hunt who describes it as “a fantastic step forward” (Donnelly, 2013) still maintain their favour believing that the pathway is playing its intended role of ensuring that people are treated in dignity, compassion and comfort during their last days of life instead of enduring invasive and life prolonging treatments (Randall and Downie, 2010, p.91). As a result of these controversies, the government ordered an independent review in 2012 chaired by Baroness Neuberger. The review finding recommends the Liverpool Care Pathway to be phased out and be replaced by a personalised end of life care plan that takes good care of the life of a patient who is facing imminent death (Department of Health, 2013). The LCP has clearly set the stage for ethical and legal controversies about patients, family rights and the role of the medical professions (Glare and Christakis 2008, p. 429). Replacing the LCP to a personalised end of life care plan may not resolve the controversies if the same transgressions persist. In that context, this paper aims to objectively review the literature and explore the challenges that contributed to its failure in order to accurately consider the future development of the recently recommended personalised End of Life Care Plan. Overview The Liverpool Care Pathway for the dying patient was developed as an integrated care pathway by the specialist palliative care team at the Royal Liverpool and Broadgreen University Hospitals NHS Trust and the Marie Curie palliative care institute Liverpool in 1997 (Ellershaw and Wilkinson, 2003, p. 11). The LCP is a structured clinical record developed to transfer the hospice model of care into other care settings (Jack, Gamble, Murphy, and Ellershaw 2003, p. 371). It aims to support clinical judgements and assist multidisciplinary team in providing optimal treatment and care for patients who are dying(Boyd and Murry 2012), as well as improve the experience of the relatives or carers during this period and into bereavement (Gambles, Roberts and Anita 2011). It focuses in providing evidence-based framework on different aspects of care required including comfort measures, discontinuation of inappropriate intervention among others (Ellershaw and Murphy 2011, p. 11). The Liverpool Care Pathway was advocated by the Department of Health (2012) as a model of good practice in End of Life care and quality makers and measures for promoting high quality care for all adults in the end of life (MCPCIL). Additionally, the General Medical Council (General Medical Council, 2010) supported it, over 20 organisations and charities as demonstrated in the consensus report for its support published by the NHS in 2012 and the National Institute for Health Care Excellence (NICE) Quality Standard for End of Life care for adults. Regardless of its high approvals and recommendations, the LCP has been blamed for delivering poor quality care to patient in their final days (Payne, Seymour, Ingleton 2008, p.392). The independent review findings identified a number of important issues that affected the ability to implement the LCP effectively in the provision of quality healthcare to persons who are almost dying or facing imminent death. Amongst which were lack of knowledge and proper understanding of the pathway, particularly on areas concerning recognising and diagnosing patients eligible for the Liverpool Care Pathway (LCP) (Chiarella 2006, p.56). Prescription of opiates and sedatives and withdrawal of nutrition and hydration, which may have brought forth apprehensions that death, had been hastened. Additionally, it was identified that poor communicationand training of staff played a significant part in its failure. As a guide, the LCP enable healthcare professionals to focus and promote high quality patient’s care when death is expected (Blaber 2008, p.190). Retrospective national survey of the bereft constantly reports that the value of end of life care is worse in hospitals than in hospices withing England and great Britain in General. It is therefore important that the NHS organisation and the clinicians recognise their responsibilities in providing a dignified death for patients and appropriate support to their families or carers as research has shown that most deaths in England occur in the hospital sector. Ellershaw and Murphy (2011) emphasizes that, the LCP is only as good as the teams who are using it, not only can it be beneficial if used correctly but also dangerous if used incorrectly or unskilfully.Essentially, the responsibility for its use sits within the governance of an organisation and must be supported by a robust ongoing education and training programme (Ellershaw and Wilkinson 2011).In addition, ethos in healthcare has changed and patients are more aware of their rights, making health care related litigations one of the growth areas of recent years (Stasky 2011, p.168). However, the law has impacted upon the way clinicians care for the patients, creating contemplation about who is responsible or accountable when a patient suffers harm. Although clinicians may have no control over resources or may be ignorant of the procedures through lack of training this however, do not exonerate them from their responsibility. When something goes wrong they are accountable to the society, the patient, organisation and the professional body that regulates them. Ethical Principles The independent review findings has prompted the author to question whether the LCP really reflect the ethical principles that provides the basis of good quality care in the final days of a person’s life. Beauchamp and Childress (2009) identifies four ethical principles that might best be seen as perspectives for facilitating decision making and clinical judgement in the management of patients. These principles are respect for patient autonomy which Donnelly (2010 p.15) defines it as “the capacity to think, decide, and act on the basis of such thoughts and decision, freely and independently”. In other words, autonomy concerns individual self-governance or self-determination (Nys, Denier and Vandevelde,2007, p.94). The principle of non-maleficence applies to the duty not to inflict harm on others (Beauchamp and Childress, 2009) while Ellershaw and Wilkinson (2011) emphasize the importance of beneficence in that it is a duty to act in a way that provides benefit to others whereas justice refers to distributive justice, the fair use and distribution of resources. Evidence received by the independent review identified that one of the fundamental issues causing difficulty was the misunderstanding and uncertainty over whether to implement the LCP as a treatment that would require the patient’s consent (if the patient has capacity) or one that would require the decision to be made in the patient’s best interest (if they lack capacity) (Hall 2008, p.678). For instance, the review panel heard that, “ relatives and carers would discover that a previously sentient person was now semi-comatose following an overnight decision by a junior clinician that the patient has been placed on LCP. Firstly, Ellershaw and Wilkinson (2011) recommend that the multidisciplinary team (MDT) make the diagnosis of the dying and be overseen by the most senior doctor ultimately responsible for the patient’s care (Ross 2012). The MDT needs to determine whether placing the patient on the pathway would be in the patient’s best interest. The proposed decision should consequently be discussed with the patient unless it is considered that having such discussion would cause more harm (non-maleficence) than good (beneficence) because of the distress it might cause (General Medical Council, 2010). Thorns and Eve (2011, p.65) shows that patients entering onto the LCP are unlikely to be competent to act in an autonomous manner. The diagnosis of a terminal illness has the ability to impinge on all aspects of personhood and can therefore impair the autonomous person’s ability to make their own choices (Buckley, 2008, p.117). At times, communicating with such patients may be difficult because they may be confused, demented or in denial therefore, in such circumstances, assumptions should not be made about a patient’s wishes but consultations should be made with other people (British Medical Association, 2013). The Mental Capacity Act (2005) propose that, if it’s practical and appropriate to do so, consultations should be made with the relatives, carers, attorney appointed under the lasting power of Attorney for their views about the person’s best interests and to see if they have any information about the person’s wishes and feelings, beliefs and values to avoid restricting the patient’s rights (Great Britain 2007, p.68). The LCP was designed to deliver comfort and dignity as well as provide information and support for families, elements of care that should not require consent. However, the independent review identified that some aspects of the Liverpool Care Pathway (Donnelly, 2013) do indeed concern treatment, such as change of medication offered to the patient. Whilst consent is not required legally, it should be provided. Thelaw states that consent must be obtained from the patient before commencing treatment, physical investigation or personal care meaning that there is a responsibility for the clinicians providing the treatment to keep the patients and their relatives or carers informed throughout their final days. Open and honest communication among patients, relatives and the healthcare professionals is essential in facilitating decisions that are in the patient’s best interest and the patient’s autonomy wish should be the driving force in making informed decisions. Decisions about nutrition and hydration are among the most emotionally and ethically challenging issues in the penultimate care offered to a patient, with the main dilemma concerning the nature and social meaning attached to the provision of food and water to the patient. Nutrition support through a feeding tube is a lifesaving therapy for patients who are unable to meet their nutritional needs and requirements orally or through the normal feeding procedure that entails eating or ingesting food through the mouth. There are considerable data indicating that it is not beneficial to provide nutrition support for patients with an irreversible or terminal illness while evidence suggests that providing nutrition support can contribute to increased suffering in patients due to increased nausea, vomiting and pulmonary oedema. Therefore, providing nutrition support to this patient population to provide comfort and reduce suffering is not science-based in any way or has been proven by research as some studies have suggested that thirst or hunger are a big problem to humans. For patients with irreversible illnesses, research has suggested that nutrition support may not benefit the patient, instead it increase the suffering and hasten death of these patients, who are supposed to be receiving the best possible healthcare in their times of need. The LCP also provides physical symptoms management, emotional support and spiritual comfort when no curative therapy is available or after making the decision to no longer continue life prolonging therapies. The transition from curative to palliative therapy should be a field of care to diminish any feeling of abandonment to the patient and family at their times of utmost need (Groenwald 1997, p.1287).The same ethical principles apply to decision making when it comes to withdrawing or withholding treatment, food and hydration in patients approaching end of life. Families of dying patients were also concerned that their relatives were being given a large amount of sedatives and painkillers that would make them drowsy and do more harm than good in the provision of palliative care. The initiation of the LCP as explained by Ellershaw and Wilkinson (2011) is to be able to recognise and diagnose when the patient is dying and has entered the last hours and days of life. The general criteria for commencing a patient on the LCP are that the patient is destined for the or that they are semi-comatose as well as incapable of taking tablets only relying on fluid food. However, critics argue that there is no research yet published that addresses prognostication of death, particularly within the time that the patient is put on the LCP. In addition to that, the MCPCIL admits that recognising of the dying is complex, and this is perhaps the reason why it does not give clear guidance as to how the MDT should diagnose prospective dying patients. Nevertheless, the British Medical Journal (BMJ, 2011) carried a study of more than 1500 terminally ill cancer patient in three different countries over a thirty year period. The objective of the study was to systematically review the accuracy of physicians’ clinical prediction of survival whereby it concluded that, doctors cannot predict the timing of death in much accuracy, although they are able to sense when things are starting to go wrong. This may be explained by the fact that patterns such as lack of response to treatment, the rate of disease progression or progressive weight loss may be recognised. Unfortunately, this study only represents patients’ with terminal cancer and of which the LCP was initially established for. Nevertheless, the LCP has diversified to include other patients with non-malignant diseases like organ failure and dementia (The gold standards framework, 2011). These set of patients may not fit so well with the LCP eligibility criteria as they may present most of the above mentioned symptoms but deteriorate on a slower rate than the recommended time frame indicated by the LCP core documentation. Despite the LCP long and widespread use, convincing studies on its value and use in end of life care are still lacking or have not been exclusively proven scientifically (Longmore 2007, p.7). Uncertainties in making clear definitive decisions can consequently cause distress to patients and relatives and instigate fear of death, especially when the patient does not die within the anticipated time or recovers. The LCP’s statement that treatment decisions can be reliably based upon prognosis is profoundly unreliable and unethical. Medical professionals are under a legal duty to act in their patient’s best interest in every decision that they make meaning they must comply with their legal duties under the Mental Capacity Act and its accompanying code of practice. The Macmillan Cancer Support (2011) released a document containing separate several incurable conditions of which physicians are advised to use as a guide for identifying patients for support and palliative care. Most critics disapproves of this tick box approach including the independent review which raised concerns that the LCP was being used as a protocol rather than a guideline and the tick box nature of the Liverpool Care Pathway (LCP) documentation was leading to poor decision. In any institution that is responsible for delivering care, poor practice needs to be examined. The LCP is just one example of where communication around decision making needs examination.The Marie Curie Palliative Institute suggests the LCP to be used when the multidisciplinary Team has agreed that the patient is dying and all reversible causes for the current situation have been considered. It enables healthcare professionals to focus on the patient care and to stop, think, assess and change care appropriately for each individual patient and their family (Gambles, Roberts and Anita 2011b). All care plans are reviewed and inappropriate interventions are stopped, particularly when these outweigh the benefits that would accrue to the patient in question or who is undergoing the treatment. Conclusion The Liverpool Care Pathway has played an important role as it formalizes the way in which end of life is provided and has undergone modifications in certain aspects for example the requirement that it must be nurse-led. However, according to Martin and Henderson (2001), it faces barriers to its implementation such as delay in the provision of resources that are necessary in its successful uptake. The Liverpool Care Pathway provides a model of good practice for the last days of a patient that is almost dying that integrates a set of interventions meant to make the life of the patient atleast comfortable in their hour of need. The widespread use of the LCP is therefore comprehended in a wide context of the developments in the society such as the shift to the choice of the patient and the authority of a clinician to choose a particular treatment plan and the raging debate about death and dying. The discussion of death as an inevitable and imminent has alos made it uptake easier and discussion among physicians and patients alike including the family and the relatives of the patient under palliative care. Whatever decisions will be made about the Liverpool Care Pathway (LCP), there is need to have a sober and forthrite debate about dying otherwise the medical professionals are likely to be blamed for inadequately understanding the final days of a dying patient. It is therefore imperative to note that when Liverpool Care Pathway is operated by well trained, well resourced and clinically sensitive medical personnel, it achieves its objectives in taking good care of a patient theat is almost dying or on the deathbed. The advocates against euthanasia have campaigned against the Liverpool Care Pathway (LCP) because of the feeling that hospitals may use it to speed up the death of patients in order to free up the resource for other patients or as a means of cost-cutting. However, there is a legitimate point of its relevance as it was initially based on the hospice policy concerning cancer patients who derive benefits from morphine and management offered by hospices. Experts now argue that the liverpoll care pathway should only be used with flexibility and discretion on the right patients and not any patient who walks into a health institution or hospital. The Liverpool Care Pathway (LCP) for the dying despite the controversies that surround its implementation as shown by the media and discussions by healthcare professionals has continued to be in practice. To make it a viable method of the management of the health of persons who are alsost dying, it would require that the hospital authorities have well-trained staff with the requisite resources in order to provide quality healthcare to those who are almost dying. References Blaber, A. 2008. Foundations for paramedic practice a theoretical perspective. Maidenhead, UK, Open University Press. Buckley, J. 2008. Palliative Care: Concordance and advance care planning Beauchamp, T. L., & Childress, J. F. (1994). Principles of biomedical ethics. New York, Oxford University Press. 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