Transcript Liverpool Care Pathway - How I Came to Love The Syringe Driver

Liverpool Care
Pathway
Central Norfolk Specialist Palliative Care Team
Presentation to
Watton medical practice
18th February 2008
Elizabeth Stallwood
Background
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The modern hospice movement was established in
response to the poor quality of care of the dying
patient
The hospice model of care is now generally regarded
as the ‘gold standard’ for the dying patient
A major challenge is to transfer best practice from
a hospice setting to other care settings
The Liverpool Care Pathway (LCP) for the Dying
Patient is a multi-professional document that
provides a template for client centred best practice
and facilitates appropriate standards of record
keeping (see Essence of Care, DOH, 2003)
Background
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The LCP is now seen as best practice for end
of life and is a major government initiative
with PPC and GSF. It is expected to be used
for all patients who are dying.
The process of evaluation for any organisation
can begin with a retrospective audit of 20
case notes (Base Review) to establish current
documentation of care. This forms part of a
national audit programme
The development of the LCP has led to
measurable outcomes of care
3 sections of the LCP
All care is now directed at comfort and dignity
Sections:
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1.Initial assessment: medical and nursing
2.Ongoing daily assessment
3.care after death
Goals encompass the following: -
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Physical : Medications and comfort care
Psychological: Resolution of tensions
Religious / spiritual: peaceful outcome.
Social: All family understand the care.
Section 1:Initial assessment
1.Diagnosis of dying:
unable to take tablets, bedbound, semi-conscious, only able to take sips of fluid.
2.Drug review
3.Anticipatory prescribing
4. Nursing review
Approaching death
Multiple organ failure
Metabolic disorder
Organic brain failure
Gradual shutdown of body function
Medications
Goal 1
Current MEDICATION assessed and nonessentials discontinued
Patient not taking oral medications
nb Insulin (see protocol)
Dexamethasone (separate driver)
Anti convulsants – midazolam 20mgs
Medication review 1
Goal 2 a
Goal 2b
AS REQUIRED subcutaneous drugs written up
according to protocol
2.1
Pain
2.2
Nausea and vomiting
2.3
Agitation
2.4
Respiratory tract secretions
2.5
Dyspnea
nb remember any anticipated emergency drugs.
Anticipatory drugs for syringe driver
prescribed for all the above symptoms
with ranges for increasing the drug
Drug protocols: Nausea and
vomiting
First line:
Halperidol
1.5 mg stat
1.5 – 3mgs /24hrs .review symptoms daily
Second line:
Cyclizine
50 mgs stat 150mgs/24hrs.review symptoms
daily
Drug protocols: Respiratory tract
secretions
First line:
Buscopan
Hyoscine butylbromide 20mgs stat
Hyoscine butylbromide 20 – 80 mgs / 24hrs
Second line:
Scopolomine
Hyoscine hydrobromide 0.4mgs stat
Hyoscine hydrobromide 0.4 – 1.2mgs/24hrs
Medical review 2
Goal 3:
DISCONTINUE inappropriate
interventions
3.1
3.2
3.3
3.4
Blood tests
Antibiotics
IV/ S/C fluids or drugs (A/B)
Not for CPR ( GSF/PPC/ACP)
Doctors signature……………………………………………………..date……
Nursing interventions
Goal 3a Discontinue inappropriate
nursing interventions
Goal 3b Syringe driver set up within
4 hours of Doctor’s order
Psychological/Insight &
Religious/Spiritual
Goal 4
Goal 5
Goal 6
Ability to communicate in English assessed as
adequate:
4.1
Patient
4.2
Family/other
Insight into condition assessed:
Aware of diagnosis
5a1
Patient
5b2
Family/other
Recognition of dying:
5b1
Patient
5b2
Family/other
Religious and spiritual needs are assessed
6.1
Patient
6.2
Family /other
Communication
Goal 7
How family/other to be informed of patients
impending death, any special people OOHs.
Goal 8
Bereavement : anticipate those at risk
Family/other given information, ie what to do after death
hospice leaflets
Goal 9
Ensure General practitioner is aware of patient’s
condition
Goal 10
Plan of care explained to:
10.1 Patient
10.2 Family
Goal 11
Family/other understanding of care plan
Section 2:
Care
Assessment and Ongoing
a Daily review of symptoms and
condition
b Note a varience if not meeting the
goal
Assessment and Ongoing Care
Are Goals are met on
 Pain, agitation, respiratory tract secretions,
nausea and vomiting
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Mouth care, micturition, medication given
safely and accurately, syringe driver checked
(where appropriate), bowels assessed
Section 3:Care After Death
Goal 12
GP practise contacted re: patients death
Goal 13
Procedure for laying out followed
Goal 14
Procedure following death discussed -to include
OOHs.
Goal 15
Family/other given information on procedures
Goal 16
NOT APPLICABLE TO COMMUNITY SAMPLE
Goal 17
Necessary documentation and advice is given to
the appropriate person
Goal 18
Bereavement leaflet given
Conclusions
The Liverpool Care Pathway for the Dying prompts the
following KEY FUNCTIONS:
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DIAGNOSIS of dying
ANTICIPATION and PLANNING of the appropriate
care
DISCUSSION with patients and relatives about the
care (sometimes difficult conversations + DNAR)
METICULOUS practice at this precious time