Liverpool Care Pathway case studies
Your patient, Bob Daniels:*
- A retired, 73-year-old farmer
- Registered with your practice for 30 years, widowed several years ago
- End-stage heart failure secondary to ischaemic heart disease
- On maximum tolerated medicines for heart failure
- Currently an in-patient following admission for increasing breathlessness
The prognosis: The hospital registrar advises you that Bob’s condition will continue to deteriorate
and he is not expected to last more than a few days. The patient is fully aware that he is dying.
The family: His daughter, Karen, a registered nurse has arrived to be with her father. Bob wants to
die at home. Karen agrees to assist, however, she is concerned that she may need specialist palliative support to manage
her father’s distress caused by his breathlessness.
Your network: Eighteen months previously you had a training session with a district nurse, who is
the LCP facilitator in your region. Your practice, along with others in the region, has an existing relationship with
the hospice. After consultation with the district nurse, both you and Karen are confident that quality care can be provided.
What do you do? You are sent a copy of the community LCP document from the hospice. With the district
nurse and Karen, you construct a care plan with prescriptions for oxygen, anxiolytics and opiates to be used on an as
required (prn) basis. The district nurse agrees to visit Bob daily and you will phone every morning and evening. At Bob’s
request, Karen contacts several of his friends and neighbours. The LCP document is held at the bedside allowing each
member of the team to record visits and make notes. You also update Bob’s medical record at the practice with brief
notes from your phone calls.
What happens? After 48 hours Karen phones, clearly upset. She reports that Bob’s condition has
worsened. Later that morning, you visit and find Bob distressed and breathless with Karen not coping well. You rule out
urinary retention and spiritual distress as guided by the Pathway, then choose to administer anxiolytics and phone the
hospice for guidance on how best to counsel Karen. That evening Karen reports that her father appears much more comfortable.
The following morning you are told that Bob died during the night.
Conclusion: In this example, it is unlikely that the LCP has significantly improved the quality of
any clinical decisions that have been made. However, it has provided a strong support framework that has given the daughter
the confidence to follow her father’s final wishes. Through good communication, encouraged by the LCP, the final
concerns of the patient have been addressed, allowing him to die in peace.
Your patient, Isla Coddington:*
- A 77 year old woman with metastatic breast cancer
- Lives at a residential care facility
- Has been bed bound for the past month due to her deteriorating condition
- Anorexic and nauseous
The prognosis: Several weeks ago, Isla’s oncologist advised her family that given her increasing
symptoms and the advanced state of the cancer, her life expectancy was weeks or days.
The family: Isla’s husband died several years ago and her two children live nearby. They visit
regularly but are worried that their mother is suffering.
Your network: The residential care facility has recently registered to use the LCP, however, you are
not familiar with the details of the Pathway. After spending half an hour reviewing the LCP process and viewing the LCP
document you are more confident.
What do you do? At a meeting with Isla’s family and the charge nurse, you explain that their
mother will be cared for according to the Pathway. This appears to alleviate their concerns. In conjunction with the
charge nurse you create a care plan that includes cyclizine (50 mg sub-cutaneously every eight hours) for her nausea.
As suggested by the LCP you pre-emptively prescribe morphine (2.5 mg, four hourly) sub-cutaneously for pain or dyspnoea
should the patient require it, with instructions to increase the dose if necessary. You also prescribe an anxiolytic
in case of agitation and an anticholinergic in case Isla develops respiratory tract secretions.
What happens? Two days later the charge nurse phones. Isla’s situation has deteriorated, however,
with the prescribed medication she appears comfortable and is still able to talk with her family.
After three days you meet with the charge nurse, carers and family as agreed in the care plan. The family mentions
that Isla briefly complained of pain, however, this was quickly relieved by increasing the morphine dose. Upon reassessment
you find that Isla is dehydrated and that this may be causing discomfort. After discussion with Isla’s family you
ask for a sub-cutaneous infusion of saline to be arranged. The next day you are told that Isla died during the night.
Conclusion: The principle benefit of the LCP was to assure family members that their mother would
receive the best possible care. This allowed the family to focus their last days on their relationship with their mother.
You were confident that the residential care nurses had clear guidance from the care plan and were not required to intervene.
The pre-emptive prescribing of morphine allowed for pain control without delay and discomfort to the patient.