Sunday, 28 October 2012

The Liverpool Care Pathway: Part 2 - Intervention

In my previous post I discussed the initial assessment which occurs before a patient is placed on the LCP. (Coincidently, Mr Trovato has also been blogging about the LCP here and here.) So, it has been determined that the patient is dying of non-reversible causes, in the last days or hours of life, and this has been communicated to the patient and their relatives and carers. The aim now is for the patient to be as comfortable and dignified as possible. The aim of the LCP is not to hasten a person's death, nor is it intended that all patients will be treated identically. Every person should be individually assessed and treated on a case by case basis. Comfort and dignity do not mean that someone needs to be asleep. This would in fact violate the LCP which has the patient's ability to communicate as its first aim. Being alert, awake and able to communicate with family and friends is arguably much more dignified than sedation, and even more comfortable.

The first step is a review of the medications which the person normally takes. Every single time a medication is prescribed and administered it is based on a risk-benefit assessment by the doctor and the pharmacist. This assessment is normally implicit, a lot of the work has already been done by the licensing authorities who decide which medication can be prescribed for which patient in which conditions. Sometimes the risk-benefit analysis becomes more explicit, for example in children, in patients with liver or kidney disease, if someone is unable to swallow, if part of their intestines has been removed, if a woman is pregnant or breastfeeding... These all alter the risk-benefit ratio. The same is true in end of life care. Side-effects which were manageable or slightly irritating may become distressing. Elderly patients in particular are often on about 6 different medications; in the over 70s it is extremely common to see daily aspirin, a statin to control cholesterol, two tablets for blood pressure, a laxative, something for diabetes, at least paracetamol for pain relief...the more illnesses one has, the more one is likely to get, and every new medication probably ends up being two in order to manage the side effects of the first.

Each of these needs to be re-considered in the light of the fact that the patient is dying and stopped if not essential. This is perfectly legitimate (CCC 2278). The particular circumstances of the patient must also be taken into account: maybe they can swallow tablets, maybe they don't want to, perhaps they are being fed through a tube... Medication for symptom control in palliatve care is often delivered using a syringe driver (sometimes called a "pump") because they give minimum discomfort and allow careful and rapid adjustment of doses. It's possible that medicines might be changed from tablets to something which can be given in the driver to make life easier for the patient.

The LCP calls for "when required" prescriptions to be written for the symptoms common in dying patients: pain, agitation, nausea or vomiting, breathlessness and 'respiratory tract secretions'. This does not mean the person will be given these medicines, it means that they can be given them as soon as they are needed, if they are needed. Only what is necessary and no more should be given to the patient for their comfort. Again the use of syringe drivers is helpful because it allows delicate control of doses which helps to prevent unwanted side effects such as sedation. The LCP does not call for sedation.

If you have ever been in hospital you will know that it is rather annoying to have your pulse, blood pressure and temperature checked every 4 hours or so. Routine monitoring of this type may be discontinued, likewise routine blood tests. However, these kind of tests do provide the means for nurses to see patients regularly, and I would imagine that frequent, regular visual observations of the patient would continue even if these tests were no longer deemed necessary.

Particular controversy surrounds the part of the LCP relating to nutrition and hydration. In fact the LCP does not call for the withdrawal of fluids in order to hasten death. Quite the opposite: it recommeneds that patients who can eat and drink should be encouraged to do so. However, as the body winds down, people who are dying are often not hungry, or may find it too tiring to eat or drink. Fluids (and even food) can be given by other means, but it is as important to avoid fluid overload (which can occur if the person's heart, liver or kidneys are not working well) it is to prevent dehydration as both are life-threatening. Dry mouth can be caused by things other than thirst, and good "mouth care" is essential.

"Do not resuscitate" orders (DNRs) are also sometimes controversial, but often this is because a DNR from a previous hospital admission has not been revoked, or because the patient and their family or carers have never discussed it, and by the time they do the patient is not capable of consenting.

The LCP requires that every patient be individually assessed for each of these interventions. Palliative care, unlike most areas of medicine, takes a holistic view of the patient, and the LCP is no exception, calling for emotional, social and spiritual support for both the patient and their family.

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