Liverpool Care Pathway for the dying patient

I am writing to ‘AM” in response to his/her letter Taiping Hospital snuffed out my father’s life. Firstly my condolences to you and your family on the loss of your father. I have taken some hours to write this reply to hopefully make you feel a little better by shedding some light on the reasons behind some of the actions by the doctors who treated your father. I would also like to shed some light on possibly what could have been improved on and hopefully relieve some of the negative sentiment towards Malaysian hospitals and doctors despite me not being affiliated to any of them.  

My name is Dr S, a Malaysian, and I graduated and currently work in the UK for the National Health Service. I will pitch my letter for everyone including non-medics and try not to use very technical terms or to simplify any that I use. From the story you have related, and my experience working in General Medicine, Old Age Medicine, the Emergency Department, and other critical departments, I gather that your father suffered (in simple words) a large heart attack, and as a result had rapidly progressive heart failure.

Such an occurrence in a 94-year-old is almost always not remedial no matter what is done, especially if the bulk of his heart muscle tissue is no longer functioning due to the heart attack. If at all there was any possibility of active treatment of his heart attack, it would have been early thrombolysis (administration of medication to dissolve the clot that was causing his heart attack) with the hope that the heart muscles that were starved of oxygen were not totally dead, which happens pretty quickly. Thrombolysis is not always possible, as there strict criteria and many contraindications (things that would make him unsuitable for it).

Based on what the doctors at the Taiping hospital told your relatives at the emergency department (that he had a heart attack, and that his heart was weak) and the classical sequence of events on his condition, it seems to me that they conducted the relevant tests, did the relevant examination, and concluded that he had a heart attack and a resultant heart failure very early on. The diagnosis of an acute coronary syndrome is not inaccurate, as it is a broad umbrella of a number of conditions where the heart is/was starved off oxygen, which includes what your dad had – which is likely to have been a heart attack.

In someone who is 94, even if he was quite fit and able otherwise, if it was even a slightly delayed presentation with no chance of busting the clot (thrombolysis), CCU and ICU would not be the right thing to do. ICU in simple words would be for those who need full-time monitoring and treatment for an acute problem that is very likely to be remediable (not the case in your dad unfortunately), and CCU for those who need active constant cardiac monitoring due to the potential need of immediate cardiac intervention usually signaled by cardiac arrhythmias (irregular beating of the heart) or monitoring after recent intervention which could cause arrhythmias (like if your dad was thrombolysed).

Admitting him to a standard ward was thus the most appropriate place for your dad from a medical point of view, and if your dad had the same problem in the UK under the exact same circumstances (with the assumptions I have made) – it is exactly what would have happened. Inotropes is not something I would have given and was not going to be the appropriate treatment for him at any point in time unfortunately. I am guessing that the CCU and ICU option which you were very keen on may have been standard practice in the past when you were practicing hospital general medicine which I assume you no longer do.

Touching on his diet – I don’t know what his swallowing ability was like on admission. If his swallowing was assessed and it was thought that it would be safe for him to have a solid diet – I see no contraindications for him to have enjoyed whatever food he wished for during his last days. If he had problems swallowing food safely, then a suitable diet would have needed to be considered further. A heart attack and/or a chest infection on its own or even in combination is not a contraindication for a normal diet.

I see many patients who are 94 or older, and in all cases, it is vital for doctors to make rational decisions on medical management which take into account not just the patients age, but also underlying diseases and pre-hospital quality of life (ie. self caring, self-feeding, self-cooking, mobility, etc). It seems to me that the doctor did tell your sister what your dad was suffering from and that your relatives needed to be informed, which was correct, but perhaps a more polite approach and further explanation on exactly what he had and why it was not reversible, why CCU and ICU was not an option, and why she had to tell your relatives sooner rather than later would have helped clarify things.

Communication is key – and it is something very, very strongly emphasized on in the UK health system and health education, and I think can be improved on significantly in Malaysia. I have had to tell patients relatives on many occasions that their father/mother/brother/sister/friend/son had days/hours to live, what exactly was wrong, what the management plan was, and why it was not curable, and it has always worked in keeping relatives calm, in the know, and making them feel part of the team looking after their loved ones.

A drip being absent in your fathers case is a good sign. If he had a drip with fluids running through, I assure you it would have accelerated his death and you may not have made it in time to see him alive. What could have possibly helped his breathing would be some diuretics to get rid of the excess fluid, however this would only prolong his life very marginally, as his kidneys would have likely been on the verge of not functioning at that point. Moving your father to any other ward during his final moments would not have brought your father back to how he was before he was ill – not even close to how he was.

We try very, very hard not to move elderly patients who are clearly at their final days or moments in life as it disorientates and distresses them and confuses all those looking after them creating room for errors, and does not change the final outcome in any way. An emergency trolley, CPR, and intubation again are out of the question, as it would not have changed the final outcome, and at best it would have given him many broken ribs only to die in pain and possibly choking. I am glad it was not attempted and would have been a serious error in judgment if it did.

The doctors could have however come to your aid sooner, but the aim would have been to explain things to you more clearly and ensure your dad was kept comfortable by means of palliative medication rather than to attempt any heroic measures. I take it that your dad was not very alert/responsive when the doctor arrived hence why they shone the light in his eyes – which is the correct thing to do. That the doctor denied your request for him to be intubated was neither pride nor ego but was likely to have been the correct medical decision, as it would have at the very best made things worse.

Touching on the issue on the time of death, it is acceptable for the doctor to record the time of death to be the time at which he pronounced him dead or the time at which another treating health professional saw him lifeless. Even if there was pretentious resuscitation by the doctor for 20 minutes, if the doctor felt that all this was only stopped at 20:17 and at that moment examined him to find no signs of life – it is correct for him to have recorded the time of death to be 20:17. To give you an example of an unrelated situation, if a nurse finds a patient lifeless at 6am, and calls the doctor to pronounce him dead, the time of death will be 6am even if the nurse thinks the patient had passed away at least five hours before being found.

The doctor can even chose to write down 06:30am if that’s when he arrives to see the patient, and he is not confident that the nurse made adequate assessments at 6am to be absolutely sure that the patient was dead at 6am. This is not uncommon especially for deaths through the night when the exact time is often not known.

In your father’s case, particularly when he was beginning to be breathless and distressed and was clearly near the end, what should have been initiated was a morphine, midazolam, and hyoscine continuous infusion just under the skin, with doses of each drug dependent on what exactly was the distressing issues. At one of the hospitals where I practiced, we used what is called the Liverpool Care Pathway which is a very good guidance and checklist on the management of patients at their final moments of life (which can be up to days or weeks even).

You could hopefully Google it, and I think it should be widely implemented in Malaysia if not already so. On the issue of a post-mortem, this I’m afraid I cannot comment much on as policies can vary greatly from place to place for different reasons.

Finally it is sad to see many respondents attacking the medical conduct of the doctors involved in this situation as well as attacking the practice of medicine in Malaysia, particularly the government hospitals. I will not make comparisons to the UK health system due to my current position and obligations, but I have to say that Malaysians should thank the government many times over for the standard of healthcare they receive. Some may ask why I am in the UK and have not returned to Malaysia – the reasons are personal, and is unrelated to the quality of Malaysian health care in any way.

I cannot find much fault in the medical care of your father in terms of which ward he was in, what he was allowed to eat, that he did not have a drip with fluids running, was not given inotropes, not intubated, not in CCU or ICU, and not actively resuscitated – which were all the right treatment measures. Again, I emphasize that communication is often key, and poor communication is often the cause of many misunderstandings and unhappiness, and can make a big difference in a patients management.

The most successful doctors and consultants I have come across have not been the smartest and most knowledgeable, but are often the best communicators, and I hope all doctors who are reading this, even if they ignore everything else in my response, just pay a little more attention to this aspect of their practice.

Above is taken from MKini

Below is taken from Wiki

The Liverpool Care Pathway for the dying patient (LCP) is an outline of care which a patient can expect in the final hours and days of life, which also becomes a structured record of the actions and outcomes that develop. It aims to help doctors provide end-of-life care.

The Liverpool care pathway was developed between the Royal Liverpool hospital and the city’s Marie Curie hospice in the late 1990s, to transfer practice in the dying phase from hospice to hospital. According to the National Mortality Statistics 2004, only 16% of cancer deaths and under 5% of non cancer deaths occur in a hospice.^[1] The pathway was developed to try to provide the same level of nursing expertise at the end of life as during other treatments, regardless of the patients’ chosen environment. The pathway document has an annual review by the multidisciplinary steering group who review the latest evidence and feedback from uses of the pathway to ensure that it remains up to date.

Aims

The pathway aims to guide members of the multi-disciplinary team in matters relating to continuing medical treatment, discontinuation of treatment and comfort measures during the last days and hours. Its main emphasis is uniting professional support in the fields of physical treatment, psychological support, support for carers and spiritual care. The Liverpool Care Pathway is organised into sections ensuring that evaluation and care is continuous and consistent. Professionals using the Pathway need to ensure that both patient and carers understand that the structure and focus of care has now changed and the focus is now on care and comfort during the end stages of life.

The pathway was developed to act as a guide only. It is not intended to replace the skill and expertise of a health professional. As with other clinical pathways the patient’s journey is an individual one, and an important part of the purpose of the pathway documents is to capture information on “variances”, where due to circumstances or clinical judgment different actions have been taken, or different results unfolded. The pathway simply provides the practitioner with specific prompts to act upon, and aims to alleviate symptoms and to keep patient as comfortable as possible. Its lack of complexity, and ease of use makes the structure amenable to all health disciplines.

Components

In the first stage of the pathway, the multiprofessional team caring for the patient have to agree that all reversible causes for the patients conditions have been considered and that the patient is in fact dying. The assessment then makes suggestions for what palliative care options to consider and whether non-essential treatments and medications should be discontinued. However, the pathway is not a “one-way-street” and if no further deterioration of the patient’s condition occurs, pathway-based palliative care is halted and all previous treatments are resumed.^[2] Currently this occurs for about 3% of patients put on the pathway.^[3] The pathway recommends that the carers assess how well the patient can communicate and talk to their family, to check that they understand what is happening and see if their religious and spiritual needs are being addressed. The carers are also expected to discuss the plan of care with the patient and their family.

The program also provides suggestions for treatments to manage any pain, agitation, respiratory tract secretions, nausea and vomiting, or shortness of breath (dyspnoea) that the patient may experience.^[4] Staff are pre-authorised to give such interventions as required without further authorisation, usually by subcutaneous injection, so that symptoms can be addressed as soon as needed, without further delay.

Assessment

Assessments of the effects and value of the pathway have been largely positive. A 2003 study published in the International journal of palliative nursing found that nurses saw the pathway as having a generally positive effect on patients and their families.^[5] A 2006 study published in the same journal found that, despite some “initial skepticism”, the doctors and nurses who were interviewed saw the approach as having a valuable place in hospice care.^[6] A multi-center study was published in 2008 in the Journal of palliative medicine that found that nurses and relatives thought that the approach improved the management of patients’ symptoms, but did not significantly improve communication.^[7] The authors concluded that they “consider LCP use beneficial for the care for dying patients and their family.”^[7] A 2009 study published in Journal of pain and symptom management studied the impact of the pathway on the end-of-life care of over three hundred patients and found that it produced a large decrease in the use of medication that might shorten life and increased patients’ involvement in their medication and care.^[8] A 2009 survey of 42 carers providing the pathway was published in the Journal of palliative medicine, it found that 84% were “highly satisfied” with the approach and that it enhanced patient dignity, symptom management and communication with families.^[9]

Jonathan Potter, the director of the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians stated in 2009 that their audits showed that “where the Liverpool Care Pathway for the dying patient (LCP) is used, people are receiving high quality clinical care in the last hours and days of life”.^[10] The 2009 audit looked at end-of-life care in 155 hospitals, and examined the records of about 4,000 patients.

Reception

A 2008 article in The American journal of hospice & palliative care criticised the Liverpool Pathway for its traditional approach and not taking an explicit position on the artificial hydration for critically ill patients.^[11] A 2009 editorial in the Journal of Clinical Nursing welcomed the impetus towards providing improved care at the end of life and the more widespread use of integrated care pathways, but warned that much more research is needed to assess which of the several approaches that are in use is most effective.^[12] In 2009 The Daily Telegraph wrote that the pathway has been blamed by some doctors for hastening the death of some mortally ill patients, and possibly masking signs that the patient is improving.^[13] This story was criticised by the Association for Palliative Medicine and the anti-euthanasia charity Care Not Killing as inaccurate.^[2][14] In contrast, The Times welcomed the pathway as an attempt to address patients’ wishes and warned about “alarmist” press coverage of the scheme.^[15] The Times also interviewed a palliative care nurse who uses the protocol, she stated that:^[16]

In contrast to previous decades, where “almost every death was a crisis”, the pathway provides an equitable standard of care that involves regular checks to make sure patients are not suffering unduly or receiving inappropriate tests or drugs…We can’t avoid the inevitable, but you, me and anyone is entitled to the best care in the last hours of our lives. The LCP is one model that helps. It’s not always the answer, but it’s a step in the right direction.

Version 12 of the LCP was launched on 8 December 2009, after over two years of consultation. Amongst other revisions, it includes new decision making support on whether or not to start the LCP; highlighted guidance to review the appropriateness of continuing on the pathway at any time if concern is expressed by either the patient, a relative, or a team member; and new prompts to support decisions on artificial nutrition and hydration.^[17][18] An editorial in the BMJ judged the new release did “much to tackle recent criticisms”.^[19]

See also

• Medical social work
• Palliative medicine
• Pain management
• Terminal illness

Source_

1. MKini:Good doctors are good communicators by Dr S
2. Wikipedia:Liverpool Care Pathway for the dying patient

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