Use of a modified Liverpool care pathway in a tertiary Asian hospital: is there still a role for it?

BACKGROUND: In 2007, the Care of the Dying clinical coordinated Pathway (CDP) was adapted from the United Kingdom Liverpool Care Pathway (LCP) and implemented in a tertiary hospital in Singapore to improve care in oncology and subsequently renal patients. With concerns about its use after the Neuberger review, an audit of patients on the CDP was performed to determine if the use of such a pathway should be continued locally. METHODS: A two-year retrospective audit of CDP use was conducted. Aspects of communication, initiation of CDP, patient monitoring, medications, nutrition, and hydration were assessed. RESULTS: In the 111 patient records reviewed, there were documented extent of care discussions with 94% of caregivers and 29% of patients before CDP initiation. Of the 88% of CDPs initiated within office hours, 90% fulfilled the inclusion criteria. All patients were monitored at least every eight hours. Seventy-three patients (66%) were prescribed opioids or sedatives and subsequently monitored appropriately, albeit 56% had no documented prior discussion with caregivers regarding medication use. Indications for opioid use were documented for all patients and only one patient had documentation of excessive sedation. Oral feeding and parenteral hydration were continued in 85% and 74% of patients, respectively. CONCLUSION: There was no documented compromise in medication safety, clinical monitoring, and provision of nutrition and hydration for patients on the CDP. However, documentation of important end-of-life decisions and conversations remain poor. Development of an alternative care tool encouraging systematic discussion and documentation of individualized end-of-life care plans should be considered.

Improvements in end-of-life care with a protocol-based pathway for cancer patients dying in a Singapore hospital.

INTRODUCTION: More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients. MATERIALS AND METHODS: The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP. RESULTS: Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group. CONCLUSION: This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital.