Methods

We were aware that our patient group differs from the hospice and hospital cohorts for which the LCP has previously been used. Modifications which were required for patients expected to die within hours were:

• Assessment of comfort hourly rather than 4-hourly due to the more acute deterioration of the patients.

• Intravenous rather than subcutaneous administration of as-required medicines.

• Intravenous rather than subcutaneous administration of infused drugs.

We abbreviated the LCP to a 6-page document that would be the final medical notes for the majority of the patients entered onto the pathway.

The pathway

Section 1 of the pathway concentrates on gathering information about the patient: underlying diagnosis, previous illnesses, relatives’ contact details and any particular spiritual or religious requirements. It also documents what discussions have taken place with relatives. This has been reduced to one side of A4 in the modified pathway.

Section 2 covers the comfort care of the dying patient. In the original LCP assessments were made every 4 h; in the ED we implemented hourly assessments of mouth and eye care, bowel and bladder care and pressure area care by the nursing staff. In addition, hourly assessments of pain, nausea, restlessness and respiratory secretions (rattle) were made. Comfort goals are recorded by the nursing staff as being achieved (A) or at variance (V). If they recorded “V”, a member of the medical staff is notified and medication administered to help achieve comfort.

Section 3 deals with the post-death administration. It is vital that this is done promptly and correctly to minimise the distress of patients’ relatives. In the majority of cases a death certificate will be issued by the ED; this may require discussion with the Procurator Fiscal in Scotland and usually with the Coroner’s office in England. If the family is not present to accept the death certificate, we ensure that we have a written time at which to telephone the family or that they are coming back for the certificate. The patient’s GP is contacted after death by the responsible medical staff.

The pathway was introduced to staff via a series of lunchtime meetings in November 2005. Once staff had seen the pathway and how it worked, it was trialled on days when the LCP lead (BP) was the duty consultant. After some minor changes to the wording and the inclusion of eye care, it was formally launched in spring 2006.

Results

The first audit was completed for the year May 2006 to May 2007.7 The initial quality markers chosen were diagnosis, length of stay, drug requirements and correct use of the documentation. Sixty-seven patients (33 men, 34 women) were admitted during this period and medical notes were retrieved for 61 (92%); the age range was 20–96 years (median 77 years, mean 70.5 years). These patients accounted for 80% of the total deaths in the department over the year. Three patients recovered sufficiently to leave the pathway and be admitted to a general ward; all subsequently died in hospital.

The diagnoses reflected the 2003 audit, with the main diagnoses being post-cardiac arrest and intracranial bleed/trauma (fig 1). It was important to ensure that we had cared for a selected group of acutely dying patients. Median survival time for the group was 2.2 h (interquartile range (IQR) 9.75 h) with a range of 5 min to 99 h.

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Figure 1

Diagnosis of patients on LCP 2006–7.

Only 40 of the 61 patients studied required medication during their period of care on the LCP. Morphine was given for pain, midazolam for agitation and hyoscine hydrobromide for respiratory secretions. The median dose of morphine used was 2.7 mg/h (IQR 5.8 mg/h) and the median dose of midazolam was 0.41 mg/h (IQR 0.84 mg/h). One patient also received 2 mg lorazepam as a bolus in the resuscitation room to control seizure activity.

It was important to audit the medication used to reassure all involved that this is not a euthanasia pathway, and these drug doses indicate that medicines were administered appropriately to achieve terminal symptom control. Opioid and benzodiazepine doses required for relief of terminal symptoms will obviously vary between individuals. However, our results on morphine and midazolam requirements are comparable with doses reported in the literature on palliative care.8 9

Documentation was less well used, with 30 of the 61 patients having incomplete pathway documentation. This appeared to be directly related to the length of stay; 26 of the 30 patients with incomplete notes died within 2 h. Patients with full documentation had a median survival of 10 h and a mean survival of 21 h.

The 2006–7 audit revealed progress, but there were areas for improvement. Documentation and general use of the pathway was covered by refresher sessions with all staff and a further survey of nursing staff involved in the pathway was completed in 2008.10

The perception and satisfaction levels of the nursing staff who had worked in the ED before, during and after the introduction of the LCP were examined. An anonymous web-based questionnaire was constructed to allow nurses to respond in an open manner (box 1). Responses were received from 17 of 20 eligible nursing staff (85%).

The responses were a mixture of free text and qualitative drop-down box selections.

The question “Can you describe your feelings about final hours care prior to the introduction of the pathway?” provided a range of answers, but with a common theme that care before introduction of the pathway had been of a high standard but “variable”. Individual patient care was thought to be “inconsistent”, and care varied according to the particular consultant or registrar attending the patient.

The responses to the question “What changes has the pathway made to your care of the patient” were very informative. The common themes were improved continuity/consistency of care, a structure to the care process, less but improved documentation, an improved confidence in the process of care and improved communication between all those caring for the patients.

Answers to the question “In what way has communication about dying patients changed since the introduction of the pathway?” were recorded as improved (29%) or greatly improved (71%) by all the nurses who responded. All the respondents to “Do you feel the care of the dying patient has improved with the pathway?” also felt it was improved (24%) or greatly improved (76%).

It was most reassuring to see that, in response to the question “Are you satisfied with the pathway and the standard of care it is currently offering?”, the respondents were all either satisfied (24%) or very satisfied (76%).

Discussion

The audit and the staff survey have both shown measurable improvement in patient care and staff satisfaction. They also indicate how to continue to improve the pathway with improved documentation, continued education, a further audit loop and a review of particular cases.

We wish to develop the pathway within our organisation by extending our knowledge of its use to other inpatient departments dealing with dying patients. Other EDs can also benefit from the LCP. It is important to stress that this pathway is not dependent on EDs having inpatient beds; the LCP allows the care information gathered at all stages of the journey to be recorded on the pathway and to be passed on to the receiving wards and staff.

Further research is planned based on the nurse satisfaction survey and will incorporate focus groups to develop some of the key themes from the earlier work and improve the use of the pathway. We also hope to start a project with the relatives of those who died on the pathway to get an understanding of how they felt they and their relative was treated.

The care of the dying patient is neither a passive nor nihilistic event. Senior decision making and structured consistent care can start in an ED and continue in the ED ward. The modified LCP has improved the quality of our care for patients and their relatives, and has improved the satisfaction of the nurses providing this care. The LCP in emergency medicine is a transferable approach that can be started in any UK ED.