End of Life Care (Pathways), Nursing and Thresholds

There is a controversy (Telegraph) that has been growing for some time, concerning the Liverpool Care Pathway for end of life care. This is a very demanding and yet rewarding aspect of nursing. I have experience of end of life nursing care in a non-specialist capacity, having worked on wards for older adults and being involved with people who have mental health and life-threatening physical health problems.

It pains me greatly not just as a scouser that something with 'Liverpool' in it should become a cause of distress, a center for debate and review. Is the pathway green and shady? Is it comprised of stepping stones, with room for two, and with time granted for your next step? Or is there a danger in some instances the path can become tarmac clad, without the succor of a services stop for basic sustenance? Can a pathway become a motorway? What does that sign say? "DON'T HOG THE MIDDLE LANE!"

What pains me seriously is that what can be a invaluable, evidenced based palliative care resource can be undermined due to the complexity of the generic and palliative care situation.

If we truly practice person-centered care then there are no care pathways.

Or, to put it another way: there are as many care pathways as there are patients and carers.

Whether you believe in social medicine, or private; whether you are laissez-faire, or leave such matters to a higher power there is no escaping the need for organisation - for order.

The mix and concentration of people, knowledge, resources and time dictates that tasks, roles and processes be delineated and assigned. We need to assure a given level of quality, and to predict things, not everything is as difficult as the weather: or death. Pathways can assist in specific contexts.

Is there scope for personalisation on a pathway? ...

Steps and pace can vary and to the left and right of center. There are many pathways though: some valid - evidenced, award winning; while others might be broad, narrow, twisted - to become a disorientating ethical loop...

Being placed on a pathway denotes a decision point, a threshold. We need to remember in all fields of health and social care practice that there are multiple thresholds to be taken into account, communicated effectively and revisited:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

'me' - existence, resilience, assets, personhood, ethics, personal values, mood, personalised care, understanding of treatment, communication skills, self-expression, loss, orientation, observation, distress, psychological assessment, sedation, beliefs, choices, :theology PURPOSE	'me' - existence, feeding, nutrition, fluids,  evidence base, Liverpool care pathway, quality of life measures, referral thresholds, prediction, resilience, reductive - holistic assessment, medication, distance, where: home-hospital-hospice? pain management, decision locale, specialism, basic nursing care, resilience PROCESS
memories, good-byes, love, compassion, carer under stress, reassurance, counselling skills, meetings with family, empathy and rapport, patient and relative engagement, life history, relative's recognition that loved one is dying, care strategies,  patient experts, patient - carer experience, communities of PRACTICE	consent, advocacy, mental capacity,  integrated working, effectiveness, independent autonomy, service access, bed availability, health & nursing in the media, scope of nursing, scope of medicine, law, medicolegal issues, whistleblowing, complaints, formal review, appeals, organisation, argumentation, professionalism, ageism, POLICY (re-PURPOSED)

The relative position of concepts above does not indicate priority.

"The LCP is not the answer to all our needs for care of the dying but is a step in the right direction."

Marie Curie Palliative Care Institute
Liverpool Care Pathway for the Dying Patient (LCP)