Background Heatherwood and Wexham Park NHS Foundation Trust manages 1200 deaths per year. Of these, an unknown percentage is expected, and appropriate for the Liverpool Care Pathway (LCP), a national tool designed to optimise care in the terminal phase. In a busy District General Hospital, our challenge is to accurately select dying patients for management on the LCP.

Aims On an acute medicine and respiratory ward, we aimed to establish: The quality of care provided for dying patients. The percentage of deaths managed on the LCP. The number and reasons for missed LCP opportunities. Method: All deaths on an acute medicine and respiratory ward during November and December 2009 were retrospectively analysed by an interdisciplinary panel using a locally developed data collection tool.

Results For 22 deaths, 20 case notes were available. Cause of death was divided into three categories: acute illness (36%), long-term condition (41%) and malignancy (23%). For all deaths, inappropriate medications were discontinued, feeding and hydration issues were addressed, and DNACPR documentation completed. 32% of deaths were managed on the LCP. Anticipatory comfort prescribing (86%), documented communication with relatives (86%), and evidence of patient comfort (71%) were superior in this group. LCP was inappropriate in the remainder because of active treatment (69%), unanticipated cardiorespiratory arrest (23%) and patient refusal to accept terminal diagnosis (8%). The panel concluded that two of these could have been managed on the LCP.

Conclusion On an acute respiratory/medical ward, 40% of deaths were appropriate for the LCP. Only two LCP opportunities were missed. Evidence of patient comfort and communication with relatives was superior for patients managed on the LCP. For gravely ill patients deteriorating despite active management, the implementation of ceilings of treatment and parallel palliative interventions such as anticipatory comfort prescribing may enhance care.