‘Less ticking the boxes, more providing support’: A qualitative study on health professionals’ concerns towards the Liverpool Care of the Dying Pathway

Leo, Silvia Di; Romoli, Vittoria; Higginson, Irene J; Bulli, Francesco; Fantini, Susanna; Sguazzotti, Erica; Costantini, Massimo

doi:10.1177/0269216315570408

Cited by 10 publications

(11 citation statements)

References 31 publications

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“…Participants found it challenging to hold the tension created by uncertainty of whether a patient might recover or not in mind, preferring to focus solely on so called ‘active management’ which they defined as disease focused treatment. The findings confirm other studies for example in intensive care [ 24 ] and other areas of the UK health service [ 10 ], including hospital doctors [ 25 ] and Italian general medicine settings [ 26 ]. Additionally, some participants had insight into their difficulties in recognising a dying patient (which is not surprising given the challenges all clinicians experience accurately predicting prognosis [ 27 ]).…”

Section: Discussionsupporting

confidence: 90%

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How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

et al. 2018

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BackgroundThere is a pressing need to improve end-of-life care in acute settings. This requires meeting the learning needs of all acute care healthcare professionals to develop broader clinical expertise and bring about positive change. The UK experience with the Liverpool Care of the Dying Pathway (LCP), also demonstrates a greater focus on implementation processes and daily working practices is necessary.MethodsThis qualitative study, informed by Normalisation Process Theory (NPT), investigates how a tool for end-of-life care was embedded in a large Australian teaching hospital. The study identified contextual barriers and facilitators captured in real time, as the ‘Clinical Guidelines for Dying Patients’ (CgDp) were implemented. A purposive sample of 28 acute ward (allied health 7 [including occupational therapist, pharmacists, physiotherapist, psychologist, speech pathologist], nursing 10, medical 8) and palliative care (medical 2, nursing 1) staff participated. Interviews (n = 18) and focus groups (n = 2), were audio-recorded and transcribed verbatim. Data were analysed using an a priori framework of NPT constructs; coherence, cognitive participation, collective action and reflexive monitoring.ResultsThe CgDp afforded staff support, but the reality of the clinical process was invariably perceived as more complex than the guidelines suggested. The CgDp ‘made sense’ to nursing and medical staff, but, because allied health staff were not ward-based, they were not as engaged (coherence). Implementation was challenged by competing concerns in the acute setting where most patients required a different care approach (cognitive participation). The CgDp is designed to start when a patient is dying, yet staff found it difficult to diagnose dying. Staff were concerned that they lacked ready access to experts (collective action) to support this. Participants believed using CgDp improved patient care, but there was an absence of participation in real time monitoring or quality improvement activity.ConclusionsWe propose a model, which addresses the risks and barriers identified, to guide implementation of end-of-life care tools in acute settings. The model promotes interprofessional and interdisciplinary working and learning strategies to develop capabilities for embedding end of life (EOL) care excellence whilst guided by experienced palliative care teams. Further research is needed to determine if this model can be prospectively applied to positively influence EOL practices.

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Section: Discussionsupporting

confidence: 90%

“…Time, opportunities, and lack of skilled facilitation for reflection and case review meant this was not capitalised upon. These experiences need to move beyond provision of education and training, which can be challenging for practitioners to attend [ 26 ], towards generating embedded real time practice-based learning experiences [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

et al. 2018

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“…Among patients with dementia, it is far more difficult to predict the end-of-life than in cancer patients [ 43 ]. The article, “Less ticking the boxes, more providing support” by Di Leo et al, [ 44 ] highlights health professionals’ concerns related to LCP use, such as problems with organizing participation in education and training programs; difficulties in including physicians; identification of the patient as dying; and interpretation of observations presented in the LCP tick-off form and documentation. Although there is existing evidence-based knowledge about pain assessment and treatment of people with dementia [ 45 , 46 ], there is currently only one prospective study that investigates pain and symptom treatment in dying NH patients, either with or without dementia [ 47 ].…”

Section: Discussionmentioning

confidence: 99%

The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

2017

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BackgroundThe Liverpool Care Pathway (LCP) is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes and for dying people with dementia.MethodsThis systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science.ResultsThe search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available.ConclusionLCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12910-017-0205-x) contains supplementary material, which is available to authorized users.

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“…The importance of specialist palliative care team support and specialist training when implementing integrated care pathways for end-of-life care was highlighted in the first randomised trial of the LCP, published 6 months after the Neuberger review. 22 23 …”

Section: Discussionmentioning

confidence: 99%

‘It doesn't do the care for you': a qualitative study of health care professionals' perceptions of the benefits and harms of integrated care pathways for end of life care

et al. 2015

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ObjectivesTo understand healthcare professionals’ perceptions of the benefits and potential harms of integrated care pathways for end-of-life care, to inform the development of future interventions that aim to improve care of the dying.DesignQualitative interview study with maximum variation sampling and thematic analysis.Participants25 healthcare professionals, including doctors, nurses and allied health professionals, interviewed in 2009.SettingA 950-bed South London teaching hospital.Results4 main themes emerged, each including 2 subthemes. Participants were divided between (1) those who described mainly the benefits of integrated care pathways, and (2) those who talked about potential harms. Benefits focused on processes of care, for example, clearer, consistent and comprehensive actions. The recipients of these benefits were staff members themselves, particularly juniors. For others, this perceived clarity was interpreted as of potential harm to patients, where over-reliance on paperwork lead to prescriptive, less thoughtful care, and an absolution from decision-making. Independent of their effects on patient care, integrated care pathways for dying had (3) a symbolic value: they legitimised death as a potential outcome and were used as a signal that the focus of care had changed. However, (4) a weak infrastructure, including scanty education and training in end-of-life care and a poor evidence base, that appeared to undermine the foundations on which the Liverpool Care Pathway was built.ConclusionsThe potential harms of integrated care pathways for the dying identified in this study were reminiscent of criticisms subsequently published by the Neuberger review. These data highlight: (1) the importance of collecting, reporting and using qualitative data when developing and evaluating complex interventions; (2) that comprehensive education and training in palliative care is critical for the success of any new intervention; (3) the need for future interventions to be grounded in patient-centred outcomes, not just processes of care.

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‘Less ticking the boxes, more providing support’: A qualitative study on health professionals’ concerns towards the Liverpool Care of the Dying Pathway

Cited by 10 publications

References 31 publications

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

‘It doesn't do the care for you': a qualitative study of health care professionals' perceptions of the benefits and harms of integrated care pathways for end of life care

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