NHS hospitals risk repeating mistakes during end of life care if they ask staff to rely on formal processes rather than focusing on patient outcomes, HSJ has been told.

  • Interviews with NHS staff show focus on process rather than outcomes
  • Younger staff may have used Liverpool Care Pathway as “crutch” due to inadequate training
  • Trusts urged to improve education and consider patient needs

Katherine Sleeman, an expert in palliative care medicine at King’s College London, has published new research into why the controversial Liverpool Care Pathway failed and how NHS trusts might avoid similar pitfalls.

She said NHS trusts needed to improve education and training for clinical staff and move away from a focus on process measures, which she said were unlikely to be implemented well if staff lacked fundamental knowledge and skills.

In May the Parliamentary Health Service Ombudsman released a report which said too many patients were dying in the NHS without dignity, and the Care Quality Commission is currently reviewing end of life care services across the NHS, which is expected to be published this year.

Trusts have also been tasked with formulating their own replacements for the pathway after it was abolished following a review by Baroness Neuberger in 2013 prompted by a high profile campaign against the pathway by families and the Daily Mail.

Dr Sleeman’s research includes interviews with 25 NHS staff, including 13 nurses as well as doctors and allied health professionals in 2009, prior to the uproar over the pathway. The interviews were carried out as part of work to improve end of life care at King’s College Hospital Foundation Trust but have never been published before.

What NHS staff said about the LCP

  • “Whatever care pathway there is, I’m always worried about people switching off their brains. Tick boxing. Putting down on paper what they have to fill in the paperwork” - senior ICU doctor
  • “Documentation doesn’t do the care for you… and there’s still an awful lot of thought and…work that you know needs to go into giving that care … so it’s not a tick box exercise” - senior nurse
  • “I think it’s dangerous at the moment at times because that clinical decision making doesn’t happen, it isn’t documented and in some instances the pathway, and that’s not the intention of the pathway and the people who developed the pathway, but the presence of the pathway, the options of the pathway actually seems to absolve people from that” - senior physician
  • “The biggest challenge I find as a nurse is not really knowing where you stand sometimes with treatment… that’s why I think the pathway is a good thing because it gives people guidance and gives us nurses something to follow” - senior nurse
  • “It provides clear guidelines for junior staff to follow and it is very clear and easy to follow and I think it provides a nice framework” - junior doctor

Dr Sleeman told HSJ: “What this paper really highlights is that if people don’t know the fundamentals of how we care for the dying, whatever tool you give them it is unlikely to be used very well because no piece of paper can replace good clinical judgement.”

“People really liked the LCP because it helped with processes, it made things clear and consistent. But those things benefit the healthcare professional and what was interesting is that no one said they thought it benefitted patient deaths, suggesting the healthcare professionals who were using it were focused too much on processes and not enough on patient outcomes.

“This was particularly strong in more junior professionals suggesting that inadequate education and training meant they grasped onto this as a kind of crutch rather than using it as the guide it was intended to be.”

She added: “Healthcare professionals talked about receiving piecemeal education and training in palliative care. If people don’t have that comprehensive basis of education and training they’re unlikely to use any care pathway well, they are much more likely to rely on it as a protocol rather than a guide, and more likely to use it poorly.”

Dr Sleeman said the two key messages for NHS trusts were to improve formal education and training, and to seek a “reorientation away from processes to outcomes so that staff move away from thinking they’ve done the right thing because they’ve prescribed morphine towards thinking they’ve done the right because their patient had pain and now that pain is better”.

“We need training in what is a good death, what does it mean for patients and what questions might we ask of patients,” she said.