Improving the Care of the Dying

Across

the Waikato DHB Region

Theresa MackenzieNZRGON, PG Dip (Pall Care)LCP Project CoordinatorSpecialist Palliative Care NurseHealth Waikato24 August, 2007.

• The LCP is an integrated care pathway first developed by palliative care physician Dr. John Ellershaw (UK) in 1997 to transfer the hospice model of care into other care settings, focusing on the last few days of life.

• It is a multi-professional document which empowers generalist palliative care health professionals to provide evidence-based end-of-life care.

• The outcomes of care are measurable & facilitate audit with the opportunity to contribute to benchmarking home-based end-of-life care both nationally & internationally.

Local & national strategies/documents underpinning the need to provide equitable access to quality care for all dying patients and their families/whanau.

• NZ Palliative Care Strategy (2001)

• NZ Cancer Control Strategy (2003)

• NZ Cancer Control Strategy Action Plan 2005-2010 (2005)

• Waikato DHB Palliative Care Strategic Project Steering Group Report (2005)

• Waikato DHB Palliative Care Strategy Plan 2005-2010 (2005)

• Waikato DHB District Annual Plan (2005)

“To develop a more responsive

system that can support a

person’s choice to die at home.

Research shows that 50-70% of

people would prefer to have the

choice of home care. At present

only 31% of people with cancer die

at home”

NZ Palliative Care Strategy, 2001, p.6.

“Hospitals mainly provide services to dying people as a

component of other services (for example acute care or

general care). This is generally not tailored for dying people”

NZ Palliative Care Strategy, 2001, p. 35

Waikato DHB Palliative Care Strategy Plan 2005-2010

• “It is recommended that the Liverpool End-of-Life pathway for the dying patient be implemented across the Waikato DHB settings i.e. hospice inpatient beds, rest homes, and continuing care facilities, home based care and acute inpatient setting.”

• “This initiative is resource intensive, requiring ongoing education and attention to minimize barriers to implementation.”

(Hewitt, 2005, p. 38).

Waikato’s LCP Pilot Project

• Joint initiative of Waikato Palliative Care Operations Network (est. 2005) & HSPCT

• Registered with the LCP Central Lead Team in the UK as an international collaborating centre

• Access to pathways, audits, international implementation plan, advice & support - at no cost

• 3 x hospital wards = LCP pilot October 2006

A snapshot

of Waikato hospital’s

pre- and post-LCP implementation

audits…

Comfort measures: discontinued inappropriate interventions in the last 48hrs of life

20

55

25

20

25

55

15

40

45

80

20

20

80

20

80

35

5

60

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

3.1 3.2 3.3 3.4 3.5 3a 3b

GoalsYes No N/a Missing

Bloodtests

A/B’s IVF NFR TPR turns

SCP

(before LCP implemented)

Cardiacdefibs

Comfort measures: discontinued inappropriate interventions in the last 48hrs of life.

85

510

80

10

10

70

20

10

90

10

5

15

70

10

90

10

75

10

510

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e

3.1 3.2 3.3 3.4 3.5 3a 3b

GoalsAchieved Variance N/a Missing

Bloodtests

A/B’s IVF NFR TPR turns

SCP

(after LCP implemented)

Cardiacdefibs

Assessment of documentation of ongoing care in the last 48hrs of life: before LCP implemented

100

5

95

5

95

5

95

15

85

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

PainAgitation RTS

NauseaDyspnoea

GoalYes No Missing

Assessment of documentation of ongoing care in the last 48hrs of life: after LCP implemented

85

710

82

1111

88

312

91

17

89

37

91

10

87

57

91

9

0

10

20

30

40

50

60

70

80

90

100P

erc

en

tag

e

Goals

Achieved Variance Missing

Benefits of the LCP

• Improves documentation• Standardises practice• For patients with malignant and non-malignant disease• Excellent education tool – medical, nursing, allied health,

under- & post graduate students• Guides pharmacological symptom management in a way

that neither hastens or postpones death

• Anticipatory prescribing prevents delays in the management of pain, agitation, RTS, & dyspnoea. - averts “crisis” admissions to hospital for dying patients with manageable symptoms in their last days or hours of life - potentially reduces the number of ‘call-outs’ for after-hours staff in hospitals & GP’s in the community to prescribe for the dying pt

continued..

• Increases confidence & knowledge of staff

• Strengthens the specialist-generalist link & facilitates access to specialist advice for complex symptom management (hospital, rest home, hospice, community)

• Measurable outcomes / Audit

• Contribution to the benchmarking of care of he dying nationally & internationally

Outcomes

• Pre- & post-implementation audits showed a marked improvement in the documentation of care

• Additional resources – LCP Community Liaison nurse & an 8 month nursing secondment to the HSPCT

• Doctors writing ‘start on Liverpool Care Pathway’ in the pt’s clinical notes

• Consultants in pilot wards unanimously agreed to continue use

• Doctors wanting to use the LCP for their ’outliers’

• H/S asking for the LCP when rotating wards

• LCP’s being used without PCT knowledge

• Dying pt’s staying under the care of their team

continued..

• Fewer referrals to SPCT for advice re: uncomplicated EoL symptom management

• LCP ‘language’ becoming embedded in nursing practice Nurses not ‘avoiding’ caring for dying patients

• Monthly LCP Network Nurse Group

• Resources endorsed by Health & Disability Commissioner

• ‘Death, Dying and the LCP’ education to Yr 2 nurses at WINTEC

LCP Implementation in the Waikato…2 years on

• 6 wards in Waikato hospital ≈ 50% of total no. of hospital deaths

• 105 LCP’s in 11mths since the pilot

• 9 wards by end of Oct ’07

• Time on LCP: 1 hour to 21 days

• 7 pts stopped LCP – 6 pts discharged home/rest home & died 2-4 days later & 1 died 21days later in rest home

• GP’s in Cambridge & Ngaruawahia (Pinnacle) in collaboration with Hospice Waikato (a ‘first’ in NZ) = ‘Community LCP’ for home-based care of the dying

• 3 x Rest Homes in Cambridge = base audit completed x1 + 3 LCP’s

• Thames Hospital (54-bed rural hospital) = base audit completed; education September ‘07

Rest homes /Rural hospitals

----------------------

Care at home ---------------------------------

Base hospital --------------------------------------------

LCP education / Project management / End-of-life care support and advice

------------------------------------------------------------------

ORGANISATIONAL SUPPORT-----------------------------------------------------------------------

New Zealand Palliative Care Strategy (2001)New Zealand Cancer Control Strategy Action Plan (2005-2010)

Waikato End of Life Pathway Implementation Plan 2006-2010

GOAL: Equitable access to quality evidence-based end-of-life care

LCP Facilitators; GP’s; Consulting Team; LCPNetwork Nurses; Hospice Community Nurses;District Nurses; Specialist Palliative Care Team

LCP Facilitators; GP’s; District Nurses;Hospice Community Nurses;Specialist Palliative Care Team

LCP Facilitators; Consulting Team;LCP Network Nurses; Specialist Palliative Care Team

LCP Facilitators; Specialist Palliative Care Team

Waikato Palliative Care Strategy; Waikato Palliative Care Operations Network

References

• Ellershaw, J.E., Smith, C., Overill, S., Walker, S.E., & Aldridge, J. (2001). Care of the dying: setting the standards for symptom control in the last 48 hours of life. Journal of pain and symptom management, 21(1); pp. 12-17.

• Ellershaw, J.E. (2002). Clinical pathways for care of the dying - an innovation to disseminate clinical excellence. Journal of palliative medicine, 5(4); pp. 617-623.

• Ellershaw J.E., & Ward, C. (2003). Care of the dying patient: the last hours or days of life. BMJ, 326; pp. 30-34.

• Ellershaw, J.E., & Wilkinson, S. (2003). Care of the dying: a pathway to excellence. Oxford: Oxford University Press.

• Jack, B., Gambles, M., Murphy, D., & Ellershaw, J.E. (2003). Nurses’ perceptions of the Liverpool care pathway for the dying patient in the acute hospital setting. International journal of palliative nursing, 9(9); pp. 375-381.

• Kitson, a., Harvey, G., & McCormack, B. 1998. Enabling the implementation of evidence based practice: a conceptual framework. Quality in health care, Sep 7(3); pp. 149-158.

• Minister of Health. (2005-2010). New Zealand Cancer Control Strategy Action Plan. Wellington: Minister of Health.

• Minister of Health. (2001). New Zealand Palliative Care Strategy. Wellington: Minister of Health.

Waikato District Health Board. (2005). Palliative care strategy plan 2005-2010. Author.