1. Dignity in Care INTEGRATED CARE PATHWAY FOR THE ADULT DYING PATIENT IN CARE HOMES
Julie Williams Macmillan Nurse Specialist for Palliative Care Education in Nursing Homes 10th July 2009

2. Dignity in Care AIMS OF THIS PRESENTATION
To introduce the Integrated Care Pathway (ICP) for the adult dying patient
Describe and outline how the pathway fits with the wider national agenda
To discuss the results of the ICP Pilot Baseline Audit
To inform about the Implementation of ICP locally

3. Dignity in Care 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)

4. Dignity in Care What is the ICP?
It was developed and initiated by the palliative care team in Liverpool. Liverpool Care Pathway (LCP)
It has been adapted for local use (ICP)
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

5. Dignity in Care 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.

6. Dignity in Care 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

7. The End of Life Care Strategy (2008) States
Dignity in Care How the ICP Relates To The National Agenda For End Of Life Care
The End of Life Care Strategy (2008) States
“ Good Primary Care Trusts will want to ensure that the particular needs and wishes of all people who are dying should be identified and addressed.
The Liverpool Care Pathway provides a well established mechanism for achieving this.
Primary Care Trusts are therefore strongly recommended to ensure that the Liverpool Care Pathway is adopted and its use audited in all locations where people are likely to die.”
All national recommendations have highlighted the importance of choice and an integrated health and social care approach to end of life care

8. Dignity in Care How the ICP Relates To The 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)
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)
End of Life Care Strategy (2008)

9. Dignity in Care Why implement the ICP in Care Homes?
People are living longer, with the percentage of deaths amongst those aged 85 and over rising
58% of deaths occur in hospitals (2008)
64% of patients would prefer to die in their own homes
(2004)
17% deaths occur in care homes collectively accounting for around 35% of all deaths (based on ONS figures for 2004)

10. Dignity in Care Why Implement the ICP in Care Homes?
To enable residents to die peacefully in their home
Reduce crisis admissions to hospital in the dying phase
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

11. Dignity in Care 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

12. Dignity in Care 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

13. Dignity in Care 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.

14. Dignity in Care 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

15. Dignity in Care 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)

16. Dignity in Care Components Of The ICP
Multidisciplinary communication/progress record sheets
Information for family and carers
Care after death
Guidelines for staff
Symptom control Guidelines

17. Dignity in Care How is the ICP being implemented in Local Care Homes?
ICP document and accompanying information leaflets ratified by PCT
Piloting in 4 GSF accredited Nursing Homes in Kirklees
Education delivered to ALL care home staff prior to ICP implementation
Liverpool Care Pathway National team involved in support with data analysis

18. Dignity in Care Key Findings from Baseline ICP Audit
Documentation from 4 Nursing Homes audited
20 Deaths in each home (Total 80 )
Deaths that occurred :
Men -20% Women -80%
Age range of residents that died : 65years to 103years

19. Dignity in Care Key Findings from Baseline ICP Audit
Diagnosis of Residents that died:
- Dementia including Alzheimer’s disease %
- Cancer %
- Long Term Conditions %
(Including Stroke, COPD, Heart Failure & Circulatory problems
Renal failure, Neurological conditions & old age )

20. Dignity in Care Key Findings from Baseline ICP Audit
Not for CPR documented %
Family/Other aware of diagnosis documented %
Family/Other aware patient dying documented %
GP aware of Patient’s condition documented– 55 – 85 %
Plan of Care explained to Family documented– %
GP practice aware of death documented– %

21. Dignity in Care Key Findings from Baseline ICP Audit
Anticipatory drugs were prescribed when residents referred to Specialist Palliative Care team
Residents with cancer had anticipatory drugs prescribed
Majority of residents with dementia and long term conditions did not have anticipatory drugs prescribed.

22. Dignity in Care Where next with the ICP Implementation?
Completed pathway data from the pilot areas will be analysed at Liverpool
Participating Care Homes will be asked to give formal feedback to facilitators via questionnaire
Feedback will be delivered to participating pilot areas following data analysis

23. Dignity in Care Where next with the ICP Implementation?
Pilot documentation will be reviewed and amended if appropriate
Train the trainer ICP
( Nominated ICP Lead in each Care Home)
Pathways will then be audited annually
Roll out ICP to further GSF accredited homes in Kirklees and Calderdale

24. “You Matter Because you are you And you matter to the end of life
Dignity in Care
“You Matter Because you are you
And you matter to the end of life
We will do all we can not only to help you die peacefully but also to live until you die”
Dame Cecily Saunders ( Founder of the Modern Hospice Movement)

25. YOU WILL NEVER BE FORGIVEN YOU IF YOU GET IT WRONG

26. YOU WILL NEVER BE FORGOTTEN YOU IF YOU GET IT RIGHT

27. For further information

28. Dignity in Care
Thank You
Any Questions?