Improving the Care of the Dying

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• 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.
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• 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.

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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)

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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.
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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).

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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

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

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

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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

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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

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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

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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

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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
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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.