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NICE encourages GPs to consider 'inherent uncertainty' at end of life

GPs are encouraged to allow for uncertainty about when a person in their care is reaching the last days of life, in final guidance issued by NICE that is intended to replace the Liverpool Care Pathway.

The guidelines mark a shift away from making a certain ‘diagnosis’ of dying and emphasise the importance of regular review and assessment once a person is thought to be in the last days of life, NICE advisors said.

They also encourage a more tailored approach to medication for symptom control and anticipatory care.

The final guidelines - which are largely unchanged from the draft unveiled in March - were commissioned after Government advisors ordered the Liverpool Care Pathway should be phased out.

Their independent review concluded the pathway had in some cases been used inappropriately, although this was largely confined to hospitals and the authors of the report praised the record of general practice in caring for the dying.

Dr Adam Firth, a GP and member of the guidelines development group, told Pulse the new NICE guidelines go ‘far beyond’ what the Liverpool Care Pathway advised as a framework for caring for people in the last days of life, in particular the shift away from a ‘diagnosis’ of dying.

Dr Firth said: ‘It goes far beyond what was in the Liverpool Care Pathway – there are elements that would be recognisable but some really important differences, particularly in moving away from the notion that we can confidently diagnose dying, to more of a recognition that there is a continuum, that there is inherent uncertainty – and having open communication about that.’

He added: ‘There are also important elements around symptom control and anticipatory prescribing, moving from a proforma approach for medications to tailored prescribing linked to expected symptom development.’

NICE - Care of dying adults in the last days of life

Readers' comments (6)

  • You got 2 hours to live mate. I'm also only going to prescribed all or none of whats on the pathway mate. You see, we GPs cannot think for ourselves nor can we make any decisions unless its written by NICE. Come to think of it, maybe we should called nurses.

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  • It is frustrating when GPs are singled out.

    Most of the complaints about the LCP come from hospital patients and relatives who were placed on the pathway without being told. As a GP we are much better at this and placing on pathway always means a discussion with family and patient.

    There were complaints about patients not being given water even though they were alert an thirsty which is not what the pathway is about.

    End of life in primary care is among the best in the world, though there are always improvements to be made

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  • If dying really matters, - make it illegal for the patient to be discharged from a hospital in the community in a move that requires a registration with a new GP for palliative care patients.

    A realistic scenario:

    Hospital discharge into the nursing home on the e-bay style auction (lowest bidder wins). Current GP 70+ miles away, so no home visits.

    Relatives register their dying parent, prognosis - weeks.

    Immediate and urgent requests on registrations:

    1- DNAR status to be signed to prevent unnecessary suffering. Meet and greet the patient and the family, who have already been briefed by the hospital and see the GP as a sign-the-form-kind-of-doctor.
    2- Palliative drugs authorisation form to be signed so they can start to be given.
    3- Syringe driver authorisation form.
    4- Home visit cover for TLC.

    Patient's file is too large to be transmitted over GP2GP (5mb limit still in place in this day and age), full physical record will turn up a week after the patient passes away, so best send your receptionist to the nearest Argos, because your fax machine is bound to run out of A4 paper if you have any intention of following this through to the letter.

    Multiply this by 10 "specialist palliative care" beds in a nursing home that has just opened on the doorstep of your surgery.

    All requests are watertight and included in the patient's GMS entitlement to GP services.

    Patient passes away, - if DOLs have clicked in place, - automatic coroner referral = discuss and report.

    Pray next bed occupant has a local GP. And the one after that. And the one after that.

    Practice income per servicing such patient, if you are lucky and the patient is registered on the quarter cut-off, - a quarter of the yearly capitation payment (that's £19.50 grand total for a bog-standard GMS contract).

    Good luck, doctors.

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  • Thanks NICE
    GP s knew this 100 years ago!
    As said above the issue was with the inappropriate application of the LCP by some inexperienced hospital staff and or poor communication often contributes by ward understaffing

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  • Anonymous | Practice Manager17 Dec 2015 0:48am

    Outstanding job of putting this so clearly. Well done. Scarily prescient. And they wonder why the system is falling apart.

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  • Most comments above are sensible. It is the pathways that cause trouble. GPs are sensible and caring individuals.They know, intuitively,and through their many years in their profession, how to deal with end of life care. They would be able to give superlative care if they were allowed much more time to spend with dying patients, with or without any payment. Learning while working is GPs greatest asset. Time applies to surgery as well as home visits as well as dying patients. Complaints will also reduce. GP stress will disappear. Patient satisfaction will sky rocket. TIME win win win.

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