Royal College of Physicians: National audit shows dying patients receive high quality care

Monday, 14 September 2009 12:00 AM

The second National Care of the Dying Audit of Hospitals (NCDAH) published today, shows that patients on the Liverpool Care Pathway for the Dying Patient (LCP) are receiving high quality care in the last hours and days of life.

The audit covers the use of the LCP in 155 hospitals, looking at the records of almost 4000 patients. The audit was led by the Marie Curie Palliative Care Institute Liverpool (MCPCIL) in collaboration with the Clinical Standards Department of the Royal College of Physicians (RCP) supported by Marie Curie Cancer Care & the Department of Health End of Life Care Programme.

The audit results are as impressive as those of the first audit, published in 2007. This shows that standards of patient care remain high, and underlines the value of the LCP in providing a framework in which clinical judgement can be exercised for the benefit of individual patients.

Questions posed by the audit and key findings:

Do all patients have medication for agitation or restlessness by a continuous subcutaneous infusion?

This audit of patients whose care was supported by the LCP showed that, even in their last 24 hours, 65% of patients needed no continuous subcutaneous infusion of medication to control distress from agitation or restlessness. 31% had low doses of medication to relieve symptoms delivered by a subcutaneous infusion, the remaining 4% required higher doses. These findings indicate, that dying patients receive good clinical care, tailored to the individual and their distress, when supported by the LCP.

The LCP supports the management of distress caused by agitation and restlessness in dying patients with medication given at an appropriate dose in relation to the severity of the symptom.

Do patients die in pain and distress?

In the last 24 hours of life the vast majority of patients are reported to be comfortable. This is demonstrated by the four hourly assessments recorded on the LCP.

Has the spread of the LCP increased since Round 1?

The Audit demonstrated increased spread of the LCP in Round 2 (2008/2009) compared with Round 1 (2006/2007): The number of participating hospitals has increased in Round 2 by 31% (from 118 to 155). The number of patient data sets submitted has increased by 46% (from 2672 to 3893).

Is the LCP just for Cancer Patients?

The proportion of patients with a diagnosis other than cancer has increased from 55% in Round 1 to 65% in Round 2, which further supports the use of the LCP for all patients irrespective of diagnosis.

Has privacy improved for dying patients in hospitals?

Following the results of the second round of the audit, it has shown that the number of side rooms available has increased.

Do patients on the LCP receive artificial fluids?

One in ten patients were recorded as receiving artificial hydration.

How does the audit influence managers in the NHS?

New in this Round of the Audit are 3 Key Performance Indicators (KPI's) that managers in healthcare use to monitor and improve care:

. Spread of the LCP
. Anticipatory prescribing for the key symptoms in the last hours / days of life
. Compliance with completion of the LCP

A key recommendation in the Audit is that hospitals collate a remedial action plan in response to the audit key findings and the individual hospitals results.

How does the audit influence the development of the LCP?

Findings from the audit together with widespread consultation will inform further development of Version 12 of the LCP which is currently out for consultation and will be launched on 25th November 2009.

Key areas identified for further improvement:

Communication

Whilst communication regarding the plan of care and recognition that the patient had entered the dying phase was generally undertaken with relatives/carers (achieved in 72% and 76% respectively), this could be further improved and would include better access to written information

Spiritual care

Assessment of spiritual and religious needs and support to patients and their relatives / carers is poor (achieved in 30% and 50% respectively)

Education and Training

Hospitals reported continuing education programmes for care of the dying - 74% for medical staff, 84% for nursing staff, and 58% for non-qualified clinical staff. Only 39% of hospitals had an LCP Facilitator.

Dr Jonathan Potter, Clinical Director, Clinical Effectiveness and Evaluation Unit,

"The second round of the national audit of care of the dying demonstrates that, where the Liverpool Care Pathway for the dying patient (LCP) is used, people are receiving high quality clinical care in the last hours and days of life."

Professor John Ellershaw, Director, Marie Curie Palliative Care Institute Liverpool said:

"Hospitals need to recognise that care of the dying is part of their core business. To achieve excellence in the last hours / days of a patient's life, all health care workers caring for dying patients and their relatives / carers should undertake training and education in care of the dying. A good death should be the expected not the exception! "

"How we care for dying patients is an indicator of the patient experience across our organisations."

Thomas Hughes-Hallett, Chief Executive of Marie Curie Cancer Care, and Chair, End of Life Care Implementation Advisory Board

''Time is of the essence; care of the dying is everyone's business''

For further information about the audit please contact

RCP PR Manager Linda Cuthbertson on 020 3075 1254 / 0794 105 7494 or via email on linda.cuthbertson@rcplondon.ac.uk.

For further information about the Liverpool Care Pathway for the Dying Patient (LCP) please contact Deborah Murphy, National Lead Nurse - LCP, Marie Curie Palliative Care Institute Liverpool on 0151 706 2274 or via email on lcp.enquiries@rlbuht.nhs.uk

Notes to editors

. The Marie Curie Palliative Care Institute Liverpool (MCPCIL) has pioneered the implementation of the LCP. This programme is recognised nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and provide support to their relatives / carers. . This National Audit is unique in the world in both size and scope collecting data from 155 Hospitals representing nearly three quarters of hospitals in England and in a parallel pilot audit undertaken in Northern Ireland hospitals.

. The Royal College of Physicians of London is responsible for standards of postgraduate training and education for physicians. It provides a huge range of services to its 20,000 Members and Fellows and other medical professionals. These include delivering examinations, training courses, continuous professional development and conferences; undertaking clinical audits; publishing newsletters, guidelines and books through to maintaining the College's historical collections. It also leads medical debate, and lobbies and advises government and other decision-makers on behalf of its members.

. More than half of all deaths in England occur in the hospital sector (ONS, 2005). So high quality personal and nursing care is essential for the comfort of the dying patient and for the hospitals to provide appropriate support to carers.

. The Liverpool Care Pathway for the Dying Patient (LCP) has been recommended for use as a template of best practice in the last hours and days of life in UK National policy (DH 2006, 2008) and more recently in the National End of Life Care Strategy: Quality Markers and Measures for End of Life Care (2009). The first National Care of the Dying Audit in Hospitals (NCDAH) of 2672 patients was undertaken in 2006/2007 based on the standards of care within the LCP.

. The second National Care of the Dying Audit Hospitals (NCDAH) includes 3893 Patients whose care was delivered supported by the LCP. This cohort represented 114 Hospital Trusts across all 10 Strategic Health Authorities. A prospective audit design was used to gather LCP data from up to 30 consecutive deaths in each of the participating hospitals between 1st October 2008 and 31st December 2008.

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