Julie Williams Macmillan Clinical Nurse Specialist

Nursing Homes4th July 2008

INTEGRATED CARE PATHWAY FOR THE ADULT DYING PATIENT

IN CARE HOMES

AIMS OF THIS PRESENTATION

• To introduce the Integrated Care Pathway (ICP) for the adult dying patient

• To describe the impact of potentially poor care of a dying Patient

• Describe and outline how the pathway fits with the wider national agenda

INTEGRATED CARE PATHWAY (ICP) A DEFINITION

An integrated care pathway determines locally agreed multidisciplinary practice, based on guidelines and evidence where available, for a specific patient/client group. It forms all or part of a clinical record, documents the care given and facilitates the evaluation of outcomes for continuing quality improvement”. (National Pathways Association 1998)

1. What is the ICP?

• It was developed and initiated by the palliative care team in Liverpool. Liverpool Care Pathway (LCP)

• A map/tool/framework for the delivery of planned care to the resident during the dying phase

• It is a multi-professional document

• Provides a method of coordinating and standardising care – reducing practice variations

2. What is the ICP?

• An evidence-based legal document, incorporating guidelines which reflect current good practice

• Provides a mechanism for continually monitoring and evaluating processes, practices and outcomes of care delivered

• It details tasks, sequences and timescales.

• It has been developed to transfer to all care settings.

The ICP is NOT

• A criticism of current practice• Totally prescriptive• Just a nursing document• Undermining of professional

knowledge, skill and competence• Complicated• WRITTEN IN STONE

1. How the ICP Relates ToThe National Agenda For End Of Life Care

• The Cancer Plan (2000)

• National Service Framework for Coronary Heart Disease (2000)

• National Service Framework for Older People (2001)

• The Gold Standards Framework (2003)

• Cancer Services Collaborative Improvement Partnership (2003)

2. How the ICP Relates ToThe National Agenda For End Of Life Care

• Building on the Best, Choice, Responsiveness and Equity in the NHS (2003)

• National Service Framework for Renal Services (2004)

• National Service Framework for Long Term Conditions (2005)

• Our Health, Our Say (2006)

• Building on Firm Foundations- Improving end of life care in care homes (2007)

3. How the ICP Relates ToThe National Agenda For End Of Life Care

NICE guidelines Improving Supportive and Palliative Care for Adults with Cancer (2004) states

“In all locations the particular needs of patients who are dying should be identified and addressed. The Liverpool Integrated Care Pathway provides one mechanism for achieving this.”

All national recommendations have highlighted the importance of choice and an integrated health and social care approach to end of life care

The impact of potentially poor care of a dying resident

• Complaints

• Influence on the bereavement process

• Staff and relative dissatisfaction

“ What might have been”

1.. Why implement the ICP in Care Homes?

• 56% of deaths occur in hospitals (2003) • 64% of patients would prefer to die in their

own homes(2004)

• 17% deaths occur in care homes (2008 Professor Mike Richards)

• Reduces crisis admissions to hospital in the dying phase

2. Why Implement the ICP in Care Homes?

• To enable residents to die peacefully in their home

• To enable relatives and carers to provide care, be kept informed and have positive lasting memories if possible

• Staff involved have a sense of satisfaction that a “good death” has been achieved

1. Benefits of using the ICP in Care Homes

• Promotes proactive high quality, efficient, effective and equitable care

• Enhances good communication and teamwork

• Gives permission to discontinue regimes

• Informs on symptom control

• It can save time and reduce documentation.

• It helps prevent crisis intervention

2. Benefits of using the ICP in Care Homes

• Empowers and increases staff competence and confidence in caring for dying residents and their families

• Sensitive, One record Up to date - provides

evidence of quality care given to residents and families

• It can highlight and identify education, training and resource needs.

• It promotes the effective use of resources

• It can prevent repetition

• It provides data for audit and reflective practice

Considerations For Inclusion On The On The ICP

• The resident has a known irreversible life threatening illness of any aetiology.

• Reversible causes for the resident’s current deterioration have been considered and appropriately managed.

• Intensive care and resuscitation have been discussed by the team and have been deemed inappropriate.

Criteria For Inclusion On The ICP

The Multidisciplinary Team has agreed that the resident is dying and 2 of the following apply

• The resident is bed bound • The resident is semi-comatose • The resident is only able to take sips of

fluid • The resident is no longer able to take

tablets

1.Components Of The ICP

• Initial assessment

• Ongoing assessment and documentation of care on a 4 and 12 hourly basis

• Outcome Measures (Goals) for each section

• Variance recording Goal Achieved (A) Goal not achieved (“V” for Variance)

2.Components Of The ICP

• Multidisciplinary communication/progress record sheets

• Information for family and carers

• Care after death • Guidelines for staff • Symptom control Guidelines

Analysing and auditing the completed documentation.

• Completed pathways are analysed and data is entered onto a database

• Pathways are audited annually

• Feedback is available to participating areas

When can we start implementing the ICP in Care Homes?

• Pilot in 4 GSF accredited Nursing Homes in Kirklees

• Education required prior to ICP implementation

• Liverpool Care Pathway National team will support the Pilot in the 4 Nursing Homes

WE ONLY HAVE THE ONE CHANCE TO GET IT RIGHT

People may not remember exactly what you did or what

you do But they will always remember

how you made them feel

“Cancer me and Serenity, Liza Mae”

People never forgive when we get it wrong

People never forget when we get it right

Thank You