Nursing Assignment Sample (pdf)

Running head: NURSING ASSIGNMENT
Nursing Assignment
Name of the Student
Name of the University
Author Note

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“More care, less pathway: A review of the Liverpool Care Pathway. London: Department of
Health.
Introduction
In the majority of the high-income countries, at least two-third of the patients die from
cancer in hospitals (Gao et al. 2013). Death in the healthcare institutions are estimated to rise
significantly in the next few years (Simon et al. 2012). Optimal palliative care, given to the
dying patients, suffering from cancer and family members, should be delivered under all
settings. However, in healthcare organizations, patients suffering from cancer are often
treated poorly in physical, emotional and spiritual context (Wiener et al. 2015). The members
of the family also fail to receive the required support and information via effective
communication both before and after the death of the patients (Heyland et al. 2013). Proper
training in end-of-life care is lacking in some of the stalwarts healthcare organisations. Under
the global context, there is an increase in concern for the improvement of overall quality of
end-of-life care for the critically ill patients. Numerous initiatives along with national
strategies have been framed and implemented worldwide. Among these strategies, one of the
notable names is The Liverpool Care Pathway (LCP) programme (Costantini et al. 2014)).
LCP programme for dying patients was framed during the late 1990s at the Royal Liverpool
University Hospital under the collaboration of the Marie Hospice Liverpool, Liverpool U.
The aim of the programme is to deliver hospice practices of end-of-life care to hospitals
(Costantini et al. 2014).
The aim of this assignment is to critically analyse LCP program via demonstrating
knowledge and proper understanding of the relevant evidences in relation to the quality of
care. The assignment also aims to throw light on LCP influence the assessment, planning,

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implementation and proper evaluation of the quality of the care of the patients in relation to
diverse service users.
Debate on the Selected Statement of LCP
The debate centring the LCP has highlighted an in-depth reluctance in the society of
UK to address cases related to mortality via the patients, their family members and healthcare
professionals(Knights, Wood and Barclay 2013). Hospitals are regarded are places used to
heal the life of patients and acceptance of death is translated giving up. Yet from time
immemorial, an integral part of physician’s role is to ease patient’s pathway to death during
end-of-life care. LCP attempts to operationalise this basic guidance into practical steps. One
of the principal aim of LCP is to initiate open and clear communication with the patient, their
mainly members and multidisciplinary team(Knights, Wood and Barclay 2013). However,
numerous cases of LCP application have highlighted ineffective communication between the
patients and their family members with the healthcare professionals. The main reason behind
this is, LCP provides an outline of end-of-life care and hence in-corporate inexperience,
anxious or reluctant professionals within difficult areas of communication which generates
majority of complains in relation to end-of-life care (Knights, Wood and Barclay 2013).
According to the reports published by RamasamyVenkatasalu, Whiting and Cairnduff
(2015), numerous healthcare professionals perceived the application of LCP under critical
care settings as an important yet well structured tool which supports quality end-of-life care.
The framework nature of the LCP guides them to undergo care plan under logical sense of
practice. It also helped to ensure that each and every step was organised in a proper way.
Critical care nurses are of the opinion that the structured approach of LCP enabled them to
procure care in a consistent way and at the same time allowed them to set realistic goals with
evaluation and explanation of each category of care given. However, some nurses are of the

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opinion that the formatted tick-box approach in the LCP at times led them divert from their
normal way of practice of personalised care planning. This led to a tendency of
depersonalised care. Nurses also reported that the piles of paper work associated with the
LCP framework is time consuming and exhausting. In spite of high clerical burden of LCP,
nurses are of the opinion that the LCP provides specific documented evidence for palliative
decisions and interventions that help to safe-guard the quality of care. Moreover, lack of
proper LCP documentation decrease the sense of satisfaction among the nursing
professionals. This is because, in the absence of LCP, the nursing professionals are in doubt
regarding whether they are successful in meeting the right standards of palliative care and
reporting in between the shifts and transporting palliative care patients between different care
settings. With LCP principles into consideration the healthcare professionals can work in an
organised nature. This basis of this statement came from the study of RamasamyVenkatasalu,
Whiting and Cairnduff (2015) which highlighted that the discontinuation of the LCP lead to
de-skilling of the junior nursing staffs and at the same time lead to over-reliance over
palliative care team support. Nurses are of the opinion that the dis-continuation of the LCP
made nurses more reliant over the doctors who hamper the quality of care of the patients
(RamasamyVenkatasalu, Whiting and Cairnduff 2015).
On the other hand, the pragmatic cluster randomised trial conducted by Costantin et
al. (2014) over 16 Italian hospital wards showed that when LCP programme was operated
under the supervision of well-trained and resourced clinical professionals, it was successful in
generating positive results. However, Costantin et al. (2014) further highlighted in their study
that there were repeated instances of poor quality practice because of the requirement of the
box-tick exercise. The majority of the healthcare professionals are of the opinion that the
box-tick exercise lacks an overall discussion about the appropriate treatment procedure which
creates lack of clarity among the nursing professionals (Costantin et al. 2014).

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Thus it can be said that though LCP provides a framework for palliative care, it
increases the clerical burden over the healthcare professionals. Moreover, the use of LCP
framework also restricts the application of the person-centred approach for the end of life
care which creates further complication in the effective delivery of the end of life care among
the terminally and critically ill patients. Thus comprehensive application of LCP might result
in poor care place for certain group of patients, however, the results might vary with the
experience of the healthcare professionals. In other words, “more care and less pathway” is
comprehensive in achieving better end of life care.
Assessment, Diagnosis, Planning, Implementation, Evaluation
Person centred care initiates with the concept of assessment. During this phase, it is
the duty of the healthcare professionals to identify the problems via interviewing patients and
their family members. The evidence based practice based practice in assessment conducted
over the palliative care cancer patients mainly deals with collecting and recording data,
proper validation of the information and tabulation of the abnormalities (Ellis 2016). Hui et
al. (2014) is of the opinion that detection of the specific abnormalities help the healthcare
professionals to draft specific person centered care plan approach. In the diagnosis phase, it is
the duty of the medical professionals to frame person specific theory of hypothesis based on
the information that have been gathered during the assessment phase. It is the duty of a
nursing professional to assist the physicians in the critical thinking process via
communicating their clinical judgments based on the mental, spiritual and physiological need
of the patient (Ackley and Ladwig 2010). According to Hui et al. (2014), the evidence based
practice (EVB) over the diagnosis of the cancer patients for the end-of-life care mainly
highlights factors like activity tolerance constipation, anxiety, decreased cardiac output,
hypothermia, fluid volume deficient and sleep deficit. Diagnosis of all these factors help in

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framing person-centred care approach rather than relying on a common framework as
proposed by LCP programme. Planning deals with the process of developing patient’s care
plan based on the diagnosis undertaken. In order to draft a patient care plan with a person
centred approach it is the duty of the healthcare professionals to have specific SMART goals.
These goals may be short term or may be long term depending upon the individual’s outcome
(Ackley and Ladwig 2010). For example, the amount of water intake will vary per week or
per day in case of palliative care cancer patient depending upon their renal output and kidney
function. Implementation stage is the actionable of the process where the health care
professionals implement the plan in order to achieve their goals. This process can be
evaluated and can be measured simultaneously. This process of implementation is associated
with both direct and indirect care in case of palliative care patients. Direct care is procured
directly to the patient either physically (mobility support and assisting in other daily
activities) or verbally (counselling). Indirect care is procured while staying away from the
patients like monitoring and supervising (Ackley and Ladwig 2010). In the domain of person
centred care approach, Mack et al. (2012) is of the opinion that not all the dying patients are
in pain. At times their apprehension about physical pain or discomfort mainly arises from
their agitated state of mind. So it is the duty of the healthcare professionals is not to treat
every patient with sedatives (direct care) in order to treat pain. Proper monitoring (indirect
care) will help to elucidate the actual concern behind the pain and subsequently helping the
healthcare service providers to take person centred approach (Hui et al. 2014). Evaluation is
the last phase of the person centred care plan in the nursing practise. It generally deals with
bringing the individuals closer to their goals. If the evaluation process fail to provide positive
results it is the duty of the healthcare professionals to make changes in the goals and then
implement it once again depending on the individualised care needs (Hui et al. 2014).

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Application of theory to practice in relation to the chosen statement: more care and less
pathway: Person – Centred – Care (PCP)
According to Independent Review of the LCP (2013) there is a lack of evidence based
practise in LCP. Visser, Hadley and Wee (2015) is of the opinion that high quality evidence
based practise is required in palliative care. Evidence based practise in palliative care helps in
the generation of person centred care in via taking active consideration of the patient’s social,
psychological, physical and spiritual requirements. However Aveyard and Sharp (2013) is of
the argument that adequate sample size is difficult to obtain and thereby reducing the strength
of the evidence based studies in palliative care. Moreover high attrition rates can generate
inadequate follow up periods and further reducing the strength of the evidence based practise
and its application in palliative care (Aveyardand Sharp 2013). Visser, Hadley and Wee
(2015) stated that evidence based management needs to be as diverse as the concerned
patients who will at the end derive the benefits from the overall care plan.
Independent Review of the LCP (2013) reported that there are numerous allegations
stating LCP program provides terminally ill patients with no hope towards recovery. This not
only disrespects their dignity but at the same time hampers the mental state of well-being of
both the patients and their family members. This again goes against the Nursing and
Midwifery Council (NSW) Code of Conduct. NSW first code of conduct mainly highlights
the duty of the nurse to respect the dignity of the patients, to treat them as separate
individuals (person centred care plan) while ensuring the again of consent. The second code
of NSW reports that is the duty of the nursing professional to protect and promote health and
well-being of the patients and their family members via delivering high standards of practise
(NSW Code of Conduct 2015).
According to Independent Review of the LCP (2013), LCP document makes clear
documentation of the process of diagnosis dying under active intervention of the

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multidisciplinary team. Predicting accurate date of dying is difficult and placing patients in
LCP might upset families. This is because, families think that because a patient is placed
under LCP programme, the patient must be counting his or her last few days in life. This
creates distress and this is increased considerably is the pain relief is not that effective. As per
the NICE Guidelines (2015), the healthcare professionals are required to communicate with
the patient’s family in a transparent manner about the difficulty in diagnosing the actual
dying phase and the uncertainties associated with it. They must also indulge in shared
decision making process in order to frame a person centred care that lowers the distress of the
patient as well as the family members.
Clinically assisted hydration is another important aspect of the person centred care
approach in palliative care unit as per the NICE Guidelines (2015). So in spite of treating all
the patient equally in the domain of hydration, a bespoke approach is required to be
undertaken. This bespoke approach mainly states in favour of supporting the dying person to
drink water as per their wish. If the person is unable to consume liquid manually as if having
difficulty in swallowing or risk of aspiration then both the risks and benefits of drinking
liquid orally must be discussed according with the dying person and with the family of carers.
This will further lead to the refinement of the person centred care approach in palliative care
is opposed to simply relying on the prevailing framework (Independent Review of the LCP
2013). Moreover Independent Review of the LCP (2013) further stated that in spite going
blind with the provided framework, all the healthcare professionals should be trained in the
subject of proper application of hydration in palliative care and this will further increase their
knowledge toward utilizing person centred care approach.
Thus the application of theory of practice in relation to the chosen statement is
extremely significant in relation to the LCP program. IndependentReview of the LCP (2013)
highlights that the family members or the immediate group of carers of the patients spend the

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majority of their time with patients and thus is immensely concerned. Thus the
multidisciplinary team who is in charge of the patient must explain the exact role and
projected outcome of each and every steps undertaken during the end-of life-care. Providing
reasons for “step changes” to the patient family in relation to treatment will provide an
opportunity to discuss about the ideal process of care with the patient family members. This
will lead to a decrease in the overall grievances among the family of carers while helping to
frame proper person centred care plan. According to Barry and Edgman-Levitan (2012)
shared decision making process is pinnacle to patient or person centred care plan. Elwyn et
al. (2012) argued further that the revisionist person-centred inclusionary approach towards
consent that give importance to the statements of all the close relatives of the patients
involved in care is one step way forward in the person centred care plan. Moreover, the
person centred care plan evolved via informed consent and shared decision making will help
in providing more quality care to the patients in palliative unit in comparison to robust
application of the LCP programme framework.
Conclusion
Thus from the above discussion it can be concluded that the “more care and less
pathway” mainly highlights the importance personalised care plan approach along with
strong involvement f the family members while caring for palliative care patients. Thus
further importance must be given on the grounds of effective communication, shared decision
making process while delivering care to the palliative care patients in comparison to
application of the LCP programme.

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