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Improving the Care of the Dying

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NZRGON, PG Dip (Pall Care) LCP Project Coordinator. Specialist Palliative Care Nurse ... The LCP is an integrated care pathway first developed by palliative care ... – PowerPoint PPT presentation

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Title: Improving the Care of the Dying


1
  • Improving the Care of the Dying
  • Across
  • the Waikato DHB Region

Theresa Mackenzie NZRGON, PG Dip (Pall Care) LCP
Project Coordinator Specialist Palliative Care
Nurse Health Waikato 24 August, 2007.
2
  • 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.

3
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)

4
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
To develop a more responsive system that can
support a persons 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.
5
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).

6
Waikatos 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

7
  • A snapshot
  • of Waikato hospitals
  • pre- and post-LCP implementation audits

8
Comfort measures discontinued inappropriate
interventions in the
last 48hrs of life
TPR turns
Blood tests
A/Bs
IVF
NFR
SCP
Cardiac defibs
(before LCP implemented)
9
Comfort measures discontinued inappropriate
interventions in the
last 48hrs of life.
Blood tests
TPR turns
SCP
Cardiac defibs
A/Bs
IVF
NFR
(after LCP implemented)
10
Assessment of documentation of ongoing care in
the last 48hrs of life before LCP implemented
11
Assessment of documentation of ongoing care in
the last 48hrs of life after LCP implemented
12
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 GPs in the
    community to prescribe for the dying pt

13
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

14
(No Transcript)
15
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 pts 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
  • LCPs being used without PCT knowledge
  • Dying pts staying under the care of their team

16
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

17
LCP Implementation in the Waikato2 years on
  • 6 wards in Waikato hospital 50 of total no. of
    hospital deaths
  • 105 LCPs 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
  • GPs 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 LCPs
  • Thames Hospital (54-bed rural hospital) base
    audit completed education September 07

18
Waikato End of Life Pathway Implementation Plan
2006-2010



LCP Facilitators GPs Consulting Team
LCP Network Nurses Hospice Community
Nurses District Nurses Specialist Palliative
Care Team
Rest homes / Rural hospitals

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

--------------------------------- Base hospital
-------------------------
------------------- LCP education / Project
management / End-of-life care support and
advice ----------------------------
-------------------------------------- ORGANISATI
ONAL SUPPORT -------------------------------------
---------------------------------- New Zealand
Palliative Care Strategy (2001) New Zealand
Cancer Control Strategy Action Plan (2005-2010)
LCP Facilitators GPs 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
GOAL Equitable access to quality evidence-based
end-of-life care
19
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.
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