The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [61]
It is critical that nurses have the necessary training and skills for effective therapeutic communication with terminally ill patients and their relatives. For more detailed information about communication, see Chapter 5.
Prognosis
Prognostication simply means predicting an outcome (Glare and Christakis 2004) – and in the care of those who are dying, patients and their families may want information about the likely time remaining before death occurs. This can be difficult to know with much certainty but is generally easier to gauge the closer death is to occurring. Whilst studies show that patients and their relatives tend to have different information needs regarding prognosis (relatives generally wanting more detailed information than patients) (Clayton and Tattersall 2006), it is important that these are carefully assessed to ensure that the needs of all those involved with the patient can be met. Discussions surrounding prognosis should be undertaken by professionals confident in advanced communication skills and with the appropriate experience to offer an approximation on the grounds of their clinical knowledge and experience. The principles of breaking bad news (see Chapter 5) should be adhered to in undertaking discussions about prognosis.
Procedure
The importance of individually tailored care for those in the terminal phase of their lives and their relatives cannot be overemphasized. No framework, pathway or care plan is a substitute for careful assessment, information giving, listening, referral and skilled intervention. Each person will require slightly different care in one way or another and, as with all areas of nursing care, assumptions should never be made solely on the basis of previous preferences, sociocultural or religious stereotypes.
Nonetheless, some principles and interventions, whilst not to be applied without bearing in mind the individual’s needs, are important and should be routinely considered, even if not undertaken for each patient.
The Liverpool Care Pathway (LCP) provides guidance on many different aspects of terminal care including comfort measures, the anticipatory prescription of medicines, the discontinuation of inappropriate interventions (including resuscitation) and care of the relatives (both before and after the death of the patient). The pathway was developed in the late 1990s by the specialist palliative care teams at the Royal Liverpool University Hospital and the Marie Curie Centre in Liverpool in response to an obvious disparity in the quality of end-of-life care in the general setting as opposed to a specialist palliative care setting (such as a hospice). The LCP was seen as a means of enabling professionals of all specialties to provide the best possible multidisciplinary care for their patients as they enter the terminal phase of life (Kinder and Ellershaw 2003). The pathway is adaptable by individual institutions according to local practices, but in essence comprises three sections: (1) initial assessment and care of the dying patient, (2) ongoing care of the dying patient, and (3) care of family and carers after death of the patient. The key stages and patient goals of the LCP are demonstrated in Table 2.2. Care of the Dying: A Pathway to Excellence (Ellershaw and Wilkinson 2003) is a key reference book in understanding the development, implementation and evaluation of the LCP.
Table 2.2 The Liverpool Care Pathway (LCP) – key stages and patient goals
Stage Focus/stage specifics Assessment/patient goals
Initial assessment Medical assessment, including the cessation of inappropriate therapy and medication, forward planning for treatment symptoms and an assessment of appropriate nursing care needs Physical assessment
Assessment of comfort
Psychological assessment
Assessment