The Liverpool care pathway is arguably one of the real progressions and success stories of recent years. It has improved care of dying patients, classified it and helped bring about uniformity were before there was chaos (sometimes). It has helped improve understanding and treatment of the end stages of life for patients and medical staff alike and improved the care of countless patients in their final days
Nursing homes seem to have been slow to take up the LCP and still I am seeing patients in nursing homes whose care could be improved. The reasons for this seem quite clear – the nurses in nursing homes are surprisingly inexperienced when it comes to palliative care (often they are quite junior in comparison to their district nursing colleagues, to say nothing of the language barriers), equipment such as syringe drivers is often not available and homes have been slow to implement the new paperwork. The problem partly lies, in the areas that I work in anyway, that because patients are under the nursing care of the home, that they are not on the caseload of the district nurses, and this is where the expertise is
Of course it would be unfair to tar all nursing homes with the same brush and I have come across some nursing homes with excellent terminal care, but these sadly seem to be the exception rather than the rule.
Take for instance the situation I encountered this week. On a night shift for the local out of hours, a call came in for a nursing home. The initial blurb read – “on LCP, deteriorating, BP 70/40, nurse requiring advice”. It was triaged by a colleague who designated it as a home visit and I was duly dispatched.
On arrival I was greeted by a HCA who rushed me into the room. She was breathless and sweating (the HCA, not the patient) and the nurse was standing with her hand on the carotid pulse “I think she is dying”, I was informed. The lights were on full, an alarm beeped loudly from the wall, a patient with dementia was wondering in and out of the room. This was indeed the last moments of this poor patient’s life
To be placed on the Liverpool care pathway a patient has to be deemed to be in the last hours or days of life, so for the nurse to be so shocked that the patient was dying showed complete lack of understanding of this; quite what she was doing checking the patients blood pressure when the patient had ceased to become responsive was beyond me. The patient’s relatives had not been informed the patient was deteriorating and the death seems to have been – anything but peaceful. At least in terms of the attention made to the surroundings of the patient.
To top it all off, once it was clear the patient had passed, the nurse informed me we should contact the police because of “the care commission”. Quite what she meant by this was beyond me – this was a natural and expected death. I suggested this was not necessary.
I would like to think that this was an isolated incident, that the care up to that moment had been excellent. I suspect I would not be alone in thinking that this would be a naïve assumption.
I am not going to make any cheap jokes or comments – its not appropriate to the circumstances. For my part I made clear documentation as to the situation I found and passed this along to the patient’s own GP. Its just a depressingly familiar scenario in nursing homes. I might add I don’t blame the nurses – it all comes down to money – the cheapest nurses at the lowest rates, the minimum of training, the minimum of expense.