Ensuring Delivery of the Highest Quality of Care for Dying Patients

Abstract

This is the second edition of what was a well-received book on delivering high-quality and evidence-based guidance to clinicians who care for dying patients in hospitals, nursing homes, and the community. Eleven chapters promote an integrated framework directly derived from the Liverpool Care Pathway (LCP) for the Dying Patient. This unique perspective was developed between the Royal Liverpool and Broadgreen University Hospital National Health Service Trust and the Marie Curie Palliative Care Institute to adapt the hospice model and philosophy of care for dying patients to fit hospitals and other care settings. Since its initial development in the 1990s, the LCP has emerged as a multidisciplinary proactive management plan that helps document and facilitate improved communication, symptom control, and other care activities in the last days of life. It has been recognized as a model of best practice by the U.K. National Health Service. Contributing to this second edition are many multidisciplinary experts, most of whom are active in palliative medicine in Britain. The 11 chapters are divided into specific subsections. The first chapter introduces the reader to the history and development of integrated care pathways in general, before then introducing the LCP. The four key components of the LCP are reviewed here: identification of a terminally ill patient in the last few hours to days of life, assessment and management of problems, continuing assessment of these problems, and care after death. Helpfully, the LCP addresses real-world “variances,” defined as contexts when individual circumstances warrant use of another plan of action, or when different results unfold. As the book continues, we learn that the LCP has gone through numerous updates and is currently in its 12th version. The key documents and core tenets of the LCP are included as appendices at the end of the book. Integral to the LCP procedures are practices for the management of common symptoms, including pain, agitation, nausea/vomiting, respiratory tract secretions, and dyspnea. For example, the subcutaneous route for medication delivery and practical concerns, such as skin, mouth, bowel, and bladder care, are covered. Several chapters are devoted to the so-called “difficult” subjects that are not traditionally part of mainstream medical curricula, such as ethical, communication, spiritual, and religious concerns in dying patients, and bereavement support after the patient has died. Chapter 4 focuses on ethical issues, emphasizing the need for individualized decision making. Common clinical scenarios are provided to introduce such topics as treatment withdrawal and withholding, cardiopulmonary resuscitation, ventilation, nutrition, hydration, and dialysis. The controversial issues of capacity and decision making also are covered. The fifth chapter looks at communicating with dying patients, including behavioral and verbal techniques for communicating with angry patients and families, breaking bad news to patients and families, and dealing with families wishing to protect patients from the truth. Chapters 7 and 8 are devoted to the topics of supporting family, friends, and children of the patient when death approaches and providing bereavement support thereafter. The last three chapters discuss firsthand experience in the development, implementation, and dissemination of the LCP both in Britain and internationally. The authors apply a 10-step quality improvement program that includes ongoing education and training, involvement of clinical staff at all levels, and creation of demonstrable metrics for measuring the quality of care for the dying through documentation audits. The book is a well-presented excellent overview of a systematic end-of-life care pathway applicable to specialist-level palliative care professionals and other health professionals involved in the care of dying adult patients. It provides a valuable focus on common and complicated cases alike, offering vignettes that clinicians can relate to and principles that are directly applicable in practice. Although based on U.K. experience and services, caring for dying patients is a universal subject, and readers from around the world will find value in the information provided. That being said, the next edition would benefit from a broader focus on countries beyond Britain. A future edition would also do well to discuss the development of care pathways for dying children, an important population with its own unique challenges, but one which is not addressed in the second edition. Shalini Dalal, MD, is Associate Professor, Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.