Every year, approximately 500 000 people die in England, of whom almost two thirds are over 75 years old (Department of Health (DH), 2008). Given the opportunity and proper support, many people would prefer to die at home (DH, 2008). However, in the UK only approximately 18% do occur at home, with the majority of deaths occurring in NHS hospitals (DH, 2008). Although some people die as they would have wished, many do not. Many experience unnecessary pain and are treated without dignity and respect and their death is not how they would have wanted it (DH, 2008). From my experience, I believe paramedics can improve end of life care, have a huge role to play in end of life care and knowledge of the Liverpool Care Pathway (LCP) can help do this.
Government publications
With the introduction of the End of Life Care Strategy (DH, 2009), greater attention is being paid to end of life care. One of the aims of the strategy is to enable more people to die at home. It is commonly accepted that a hospital death is most frequent because people change their minds as their illness progresses (Higginson and Sen-Gupta, 2000). However, Higginson et al (2010) have found that with the right family support, patient preference is unlikely to change, but they do note that their sample size was small.
A recent government document detailing NHS reform states that there will be a move towards giving people a choice of where they would like to die and supporting people's preferences, and ensuring a ‘good’ death is achieved (DH, 2010).
History of end of life care
In 1967, after having direct experience of poor care of the dying and its lack of importance within health care systems, Dame Cicely Saunders pioneered the hospice movement (Booth et al. 2010). Hospices are considered centres of excellence for the care of the dying (Ellershaw, 2007). However, less than 5% of deaths occurred in hospices in 2008 (Office for National Statistics, 2008)—hence the need to transfer the hospice model of excellence into other health care settings and the development of the Liverpool Care Pathway (LCP).
What is the Liverpool care pathway?
The Marie Curie Hospice in Liverpool and the Royal Liverpool Hospital developed the LCP in the 1990s (Buckley, 2008). The LCP is used in the last days and hours of life with the aim of transferring the best aspects of hospice care into hospitals and other settings (Holloway, 2007; Buckley, 2008). Recognizing that a patient is deteriorating and the possibility that the patient is dying, can then prompt a review of the patient and the possible implementation of the LCP (Marie Curie Palliative Care Institute Liverpool, 2009).
With appropriate training, paramedics can play a key role in recognizing that a patient may be coming to the end of their life, and that taking the patient to the local emergency department (ED) may not be the most appropriate care pathway for the patient. One of the first goals identified by the LCP is to review all medications, discontinue non-essential medications and ensure the provision of anticipatory symptom relief medications such as analgesics and antiemetics (Holloway, 2007). The LCP is recommended as the best practice model for care of the dying (DH, 2006; 2008; 2009).
Methods
Having searched the electronic data base, Metalib, in June 2010, it is apparent there is a lot of research in palliative medicine but there is very little research that has been conducted in the emergency care setting. When starting this literature review, a literature search was conducted using the terms ‘emergency care’ and ‘end of life care’—the boolean operator AND was used. 155 results were found, however, selecting results that applied only to emergency medicine left 6 articles. A second literature search was conducted to establish the extent of end of life care research with paramedics. The search terms used were ‘paramedics’ and ‘end of life care’ the boolean operator AND was used again. 85 results were found; however, only two articles were relevant.
These two articles examined paramedics' attitudes, knowledge and training in end of life care, they did not examine the implementation of the LCP to the prehospital setting. This literature search reiterated the lack of research into end of life care in the emergency setting and the lack of evidenced based research analysing if paramedics are helping their patients achieve a ‘good’ death.
Research
Developed using evidenced based research, the LCP is a comprehensive template for the multi-disciplinary team to use in the last days and hours of life (Ellershaw, 2007). The challenges of undertaking robust randomized trials in palliative care is a hotly debated one—methodology and ethical issues are complicated in the dying, unconscious patient (Ellershaw, 2007). However, randomized controlled trials hold the most weight in the hierarchy of evidence based research (Parahoo, 2006).
The LCP was developed using motivated and interested clinical teams from around the country that recognized the improvements required in end of life care (Ellershaw, 2007). Since being implemented, the LCP has been assessed using a number of research methodologies which will now be discussed.
Jack et al (2003)
Jack et al (2003) found hospital based nurses evaluated the LCP positively. The participants reported that the LCP gave them a focused and relevant template of care to follow. In turn, this led to greater confidence and empowerment when caring for a dying patient, ensuring symptoms were managed appropriately. The qualitative data was collected using focused group interviews as described by Hek and Moule (2006). One of the main criticisms of qualitative data is its lack of scientific methods, which are unreliable and invalid (Parahoo, 2006).
A limitation that is often proposed of qualitative research is that researchers get too involved in their study and can no longer be objective (Parahoo, 2006). Although this could be a limitation of any of the qualitative research examining the LCP, qualitative research allows a considerable amount of insight into a phenomenon. This insight shares characteristics with modern nursing such as patient-centred and holistic approaches (Hek and Moule, 2006) and now also modern paramedicine (DH, 2005).
Paterson et al (2009)
In 2001, an emergency department (ED) in Scotland noted their increasing role in the care of the dying. The nursing staff reported their frustration about the lack of consistency in the care pathways followed.In 2005, they introduced an adapted LCP. In 2008, nursing staff completed a questionnaire in which all of the responses believed care of the dying patient had either improved or had greatly improved, and all of the responses felt that the LCP offered a satisfying standard of care. A limitation of this study is that only 17 nurses participated. For generalisation to the wider population the study needs to be conducted in other EDs across the country (Parahoo, 2006). However, the study does indicate the potential suitability of the LCP to emergency medicine.
Verbeek et al (2008)
Verbeek et al (2008) conducted a study examining the effects of the LCP before and after it was introduced in three different care settings in the Netherlands: a general hospital, a nursing home and a community nursing team. They found that documentation greatly improved after the introduction of the LCP, which can help improve care of the dying in the future as a patient's death has been well documented at every stage so any problems encountered can be reviewed and improved for other dying patients.
They also found that symptom control greatly improved which is often named as one of the main concerns in terminal illness. The relatives that were involved in the study only experienced one of the control groups, and were unaware about the change in practice when the LCP was introduced. This helped improve the reliability of the information gathered from relatives (Cutcliffe and Ward, 2007). The relatives that were involved in the LCP intervention group felt that symptom control was much better managed and that communication was greatly improved compared to the feelings of relatives in the control group.
The study shows that the LCP contributes to the quality of documentation and symptom management in end of life care in three different settings. However, the researchers' note the limitation that in the hospital setting the LCP was used on average for 16 hours, therefore the effects of the LCP could have been reduced.
Marie Curie Palliative Care Institute Liverpool (MCPCIL) in collaboration with the Clinical Standards Department of the Royal College of Physicians (2009)
Since 2006, the MCPCIL, in collaboration with the Clinical Standards Department of the Royal College of Physicians, have undertaken audits of national hospital care of the dying. Their 2008/2009 audit shows that 82% of hospital trusts in England are using the LCP, and of these 99% have a specialist hospital palliative care team. 61% of the patients included in the audit did not have a diagnosis of cancer, showing that the LCP has been successfully adapted from just being applicable to oncology.
The audit shows there is still room for improvement in communication and recommends the continuous close scrutiny of end of life care within hospitals to ensure performance and quality figures for end of life care are continuously improved. The publication of this audit did not support criticisms that had occurred in the media (Brooks, 2009)—the main concern being that patients are being heavily sedated until they die, and doctors failing to recognize signs of recovery. In two thirds of cases, patients did not require continuous infusion of medication in the last 24 hours of life.
Patients that were prescribed PRN drugs for agitation and restlessness, only actually received the drugs in 37% of cases. This supports the use of the LCP as a clinical decision making tool, allowing for individual patient care. Midazolam was the most frequently prescribed drug for agitation and restlessness. The average dose of midazolam given as an infusion was 10 mg over 24 hours, a low dose of a sedative drug when given over 24 hours. The average dose of midazolam given as an infusion was 10 mg over 24 hours, a low dose of a sedative drug when given over 24 hours (British National Formulary, 2011)
Discussion
With development and adaptations to the LCP, it is being applied to more types of dying patients, such as those with advanced kidney disease (Buckley, 2008). The LCP is being used increasingly in the community as a natural extension of the gold standards framework (GSF) (Buckley, 2008).
Ambulance services can often become involved as patients and relatives panic when the end of life is approaching or when a patient first begins deteriorating. As a result, paramedics have a key role to play in successful end of life care and reducing the amount of patients that are transferred to EDs inappropriately.
End of life care requires improvement and clarification. Care pathways need to be available 24/7 in the community and patient's wishes need to be established before they approach the end of their life, so that wishes are firmly recognized in their care plans and can hopefully be met.
The LCP, in combination with GSF, which recognizes patients in their last year of life and helps patients and relatives plan for their death, improves patient care. With the implementation of GSF, paramedics would have access to documentation regarding end of life care plans and better records of advanced decisions, do not attempt resuscitation and expected death documents (Buckley, 2008). These patients would be registered on an end of life care database that paramedics would be able to access via the clinical hub of the ambulance service (Gold Standards Framework, 2010).
The LCP is only as good as the multidisciplinary team implementing it and the education given to them (Ellershaw, 2007). Ambulance services will need to spend time educating their staff. Clinical leads will also be needed for successful implementation of the LCP by paramedics. Pressure to improve end of life care may provide opportunities for paramedics to specialise in end of life care, and implement changes within their ambulance service.
Conclusion
Paramedics could play a huge role in improving end of life care, further research is required to demonstrate this. Paramedics may help in achieving the government's aims of improving end of life care. Research indicates that the LCP has improved care of the dying in the hospital and prehospital setting. Although this research does not involve paramedics, it may be that their findings are transferable and that the widespread use of the LCP may improve the quality of paramedic care of the dying.
For this to be measured, research would have to be conducted assessing paramedics' current feelings towards how successful end of life care is within ambulance services in the UK.