1. Link Nurse Day May 2010 Liverpool Care Pathway Problem or Solution?

2. Problems you identified: Delays in starting LCP DNAR delays What if they live? Reluctance of Surgeons to stop active treatment/start LCP Reluctance to use the LCP Stopping the LCP Artificial fluids or not Seen as just “paperwork” Core drugs not prescribed Problems out of hours Misconceptions about LCP Automatic syringe driver prescription Lack of training-all staff Care of relatives Communication skills around LCP GPs see it as a nursing issue

3. Problems Macmillan Nurses identified: Using LCP as a means to stop treatment Prematurely starting the LCP Relatives not truly aware of the plan of care Burdensome discussions about DNAR Uncertainty about syringe drivers-when to start and dosages Uncertainty about fentanyl patches

4. LCP Version 12 Continuous quality improvement programme based on feedback, consultation and latest evidence NOT YET ADOPTED BY OUR HOSPITALS, PCTS OR HOSPICES Working towards it’s adoption here

5. Drawing on your experience and using Version 12 LCP: What clues lead us to suspect that a patient may be dying? What information in Version 12 could you use to support your negotiations with the medical team to start the LCP?

6. What are the signs that someone may be dying? Gradual deterioration Weaker Less interested in things and what is happening around them Noisy or shallow breathing Time disorientation Restlessness/agitation Bed bound Increasingly drowsy Increasingly disinterested in food & drink Increasing difficulty with oral medication

7. Starting the LCP Focused on care Diagnosis of dying is complex, uncertainty is always part of dying Consult others if wish (eg Macmillan nurse) Reversible causes for the patient’s condition have been excluded Medicines for symptom management will only be given when needed Emphasis on tailoring clinical decisions to patient’s needs

8. What does Version 12 say about: LCP = Graseby? End of treatment = LCP? Who’s job is it to initiate LCP? LCP = a one way ticket to death?

9. Graseby should be available but not all patients who are dying will require one Treatment may be continued if clinically indicated LCP not to be commenced unless MDT agree they are actually dying MDT assessment and decision to initiate LCP Reassessment should be triggered if the patient’s condition improves-any new plan of care needs careful explanation with patient/carers

10. What does version 12 advise on: Communicating with and supporting the carers? Artificial nutrition and hydration? Anticipatory prescribing?

11. Written information if desired Explain plan of care and any changes Check understanding, listen and document More guidance on decision making around fluids and nutrition Rationale given for prescribing core drugs

12. Any questions?