The introduction of the Liverpool Care Pathway strives to ensure that we recognise the imminent approach of natural death, and it is fully explained to the patient and/or the patient’s family.
The patient’s holistic needs - physical, emotional, psychological and spiritual - should be assessed and addressed as far as is possible.
There is evidence, however, which seems to indicate that clinical staff often feel uneasy about or unable to address spiritual need at any time in a patient’s journey, including as death approaches.
In an unpublished survey undertaken at North Tees & Hartlepool Trust in 2008, there had only been an attempt at addressing spiritual need in 4 per cent of patients on the LCP.
In order to address this “missing piece” chaplains in our trust, in partnership with the palliative care team, have developed a simple but effective model. Whenever a patient is placed on the LCP, chaplains are informed. One of the team then makes a timely but sensitive visit to find what spiritual needs there may be, and, if required, to address those needs.
If appropriate, further visits will be made in the ensuing days. The outcome of the visit is recorded in the LCP documentation in the section on spiritual assessment. This is not only about explicitly religious care, but spiritual and pastoral care in a broad sense. We visit all patients - those with faith of whatever kind, and those of no faith.
Chaplains see virtually all of the patients who are on the LCP (an average of 58 per month), and over 60 per cent receive multiple visits. Fewer than 3 per cent of patients/carers decline input from the chaplain. In short, 97 per cent of patients on the LCP (or their carers on behalf of the patient) receive some kind of spiritual and pastoral support in those last few days and hours at the fulfilment of their lives.
Although the implementation of this particular model has ensured that the box in the LCP documentation, which requires an assessment of spiritual needs, can be ticked, there are more far reaching benefits:
There is no more momentous time in a person’s life than their approaching death. Our visit - someone who is non-clinical and who is not part of the intimacy of immediate family - can present an opportunity to deal with unresolved issues. It may be an opportunity to seek forgiveness, or reconciliation, or any other issues that may be troubling a person as death draws near. They may want the fulfilment of their own particular religious rites.
The patient’s family
This is a very difficult time for them as they keep vigil at the bedside of a loved one. They may have questions about the LCP itself, or what to expect as death draws near, or what to do after death. Just to receive a visit from someone like a chaplain who can perhaps answer some questions, find someone else who can, or who will simply support them by regular visits in the hours approaching death has all proven to be of benefit to families.
They may also be glad of guidance about how to behave in the presence of their relative - to talk to them, to reminisce in their presence etc. Sometimes there are unresolved issues of hurt and pain that come to the fore at this time, and, again, the chaplain is well placed to address such issues.
The hospital trust
Given the choice (which they should be), most people would prefer not to die in hospital, but sometimes circumstances dictate that it is the only practical place available. In our trust - and I doubt that we are alone in this - many complaints from patients’ families emanated from the days and hours preceding death - we couldn’t ask questions; we were left on our own; no one seemed to care; could more have been done?
Since the introduction of the chaplains’ involvement in end of life care, there has been a reduction in the number of these complaints. There have been examples of families complaining about many other aspects of their loved one’s care, but not their end of life care. This is not to say that the approach to death and dying previously was without compassion or care, but that now that care is more visibly explicit in the person of the chaplain’s visit.
This work has given added focus and impetus to our role within the trust. We have an additional and valued purpose. We are better known and valued by staff, who are now more confident about referring other matters and not just issues around end of life care.
Some have suggested that our involvement would make us too morbidly death focussed. This has not been the case - in fact, just the opposite. It is a daily privilege to offer comfort to a person and/or their family at the time of approaching death. Far from being morbid, it is uplifting. And in any event, if we, as ministers of faith, cannot offer some comfort and hope to the dying and their loved ones, then why are we here?
Is this model transferable?
We are convinced that it is, and we would be happy to advise colleagues from other trusts who might like to consider replicating the model. But certain preconditions are required to make it work effectively:
- Support of the palliative care MDT, especially the consultants. As with so much in the NHS, the consultant is key and can help make things happen.
- Support of the trust board. Again, the influence of the consultant is key here e.g. to have chaplains accepted as part of the MDT.
- Support of the staff on the wards. Staff took a little time to be convinced, but a successful pilot ensured that the model was accepted. The fact that it continues to work effectively, and benefits patients and families, ensures continuing support from staff.
- Support of the chaplains. Unless we were all committed to this role in the Trust, it would be ineffective. There was some concern that this work would overwhelm our workload. This has not proved to be the case, and it in fact greatly enhances and enriches what we do.
Paul Salter is co-ordinating chaplain at North Tees & Hartlepool Foundation Trust, email@example.com