Aim: To improve the care of patients presenting to the emergency department who are acutely dying or those in whom further disease-modifying treatment is not appropriate.
Design: A quality improvement report on the implementation of a modified Liverpool Care Pathway for the Dying Patient (LCP) in an emergency medicine department.
Setting: The emergency medicine department of Ninewells Hospital, Dundee. Ninewells Hospital is the tertiary referral and teaching hospital for the east coast of Scotland and North East Fife.
Key measures for improvement: The pathway was introduced after a 2001 study and a 2003 audit showed that the department had an increasing role in the care of the acutely dying, but some inconsistency in approach. Key measures for improvement were to improve communication between staff, improve the consistency of care and improve the perceived quality of care given. Senior decision making remains a crucial element of the pathway.
Strategies for change: A modified LCP was developed and launched in November 2005. Change was managed via a series of meetings and a pilot process. Serial review and audit allowed ongoing quality review of the pathway and improvements.
Results: The care of the dying patient has become a more consistent and positive endeavour. Nursing staff are very satisfied with its use, and it is hoped that the LCP pathway can be developed further within the organisation.
Conclusions: It has been a rewarding undertaking to improve the care of dying patients, but one which has taken time and has required consistent management of change to promote the positive outcomes.
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Emergency departments (EDs) frequently identify and care for patients who are acutely dying or those in whom further disease-modifying treatment is not appropriate. This group of patients and their relatives can be immensely satisfying to care for, but can also have complex physical and psychological needs. It can be frustrating to establish a relationship and care plan for these patients and unsatisfactory to relatives and staff to pass on the care of these patients to other departments when the estimated survival of the patient will be only a few hours. The receiving departments will have to start the process of engaging with the patient and relatives from scratch and lose the benefits of the ED communication and care plan. The care of dying patients has been highlighted by the recent publication of the Department of Health end of life care strategy.1
Ninewells Hospital, Dundee is a tertiary referral and teaching hospital for the east coast of Scotland and North East Fife. The ED sees around 60 000 patients per year; these include all categories of acute adult and childhood trauma and illness, excluding planned GP admissions to specialties. The hospital has a short stay/observation ward staffed by ED doctors and nurses where toxicology, minor head injury and general short-term observation-based care is provided. This is also where end of life care is offered to those in their final hours. Since 2001 we have noted that care of the acutely dying is an increasing role of the department.2 An audit in 2003 showed that we had cared for around 40 dying patients per year in the short stay ward.3 Audits carried out in spring 2004 and 2008 showed that nursing and care home residents were only a small and not an increasing part of this workload. The main diagnoses were post cardiac arrest and intracerebral haemorrhage. Verbal and anecdotal feedback to the audit from all groups of staff involved encouraged us to believe that high standards of care were being given but there was frustration, particularly from the nursing staff, of a lack of consistency in the care pathways followed.
In 2005 we decided to further improve the care of acutely dying patients. The aim was to introduce consistency to the care given and to improve the experience involved for both the relatives of the dying patient and the nurses and doctors involved. We chose to accomplish this by the introduction of a short integrated care pathway based on the Liverpool Care Pathway for the Dying Patient (LCP).4
The LCP is a multi-professional document which provides an evidence-based framework for end of life care. It aims to help doctors and nurses achieve a high standard of care for patients dying in any care setting.5 It can be adapted for acute environments where managing death has not been the primary role of the department. It has been used in acute hospital wards, hospice and care home settings when it is clear that the patient is in the last days of life.6 In the emergency medicine setting, adaptations to the LCP are required to make it suitable for guiding care in the last hours of life. The target group was those who are rapidly dying and expected to die within 24 h. Typically, patients will be unconscious, self-ventilating, deteriorating and have a diagnosis incompatible with survival. To ensure that the LCP was commenced appropriately, the multidisciplinary team led by the consultant on duty agreed that the patient was acutely dying with no potentially reversible factors in their illness. We feel that this senior staff leadership is important.
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.
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.
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.
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%).
Box 1 Key measures
“Can you describe your feelings about final hours care prior to the introduction of the pathway?”
“What changes has the pathway made to your care of the patient?”
“In what way has communication about dying patients changed since the introduction of the pathway?”
“Do you feel the care of the dying patient has improved with the pathway?”
“Are you satisfied with the pathway and the standard of care it is currently offering?”
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%).
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.
Competing interests None.
BP acts as guarantor of the paper, accepts full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.
Provenance and Peer review Not commissioned; externally peer reviewed.
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