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To explore the factors influencing whether GPs sign the DNAR order as part of the LCP
  1. Robert Chew1 and
  2. Karen Forbes2
  1. 1St Francis Hospice, Romford, UK
  2. 2Bristol University, Bristol, UK


Background End of life care is currently a government and national priority. The Liverpool Care Pathway for the Dying Patient (LCP) is an evidence-based multiprofessional document which aims to optimise end of life care. In May 2006 the LCP was introduced into a primary care locality within a London PCT. An audit carried out on the first 20 patients to be placed on the LCP noted that the ‘do not attempt resuscitation’ (DNAR) order had been signed by their general practitioner (GP) in only seven out of the 20 patients.

Aims and objectives To explore the factors influencing whether GPs sign the DNAR order of the LCP. To explore what helps or hinders GPs to sign DNAR orders and to propose actions facilitating completion of such orders.

Method Semi-structured interviews with seven GPs and four nurses were carried out between April 2008 and September 2008. Grounded theory analysis was used.

Results The LCP is a nurse led process in the primary care setting that was studied. Facilitatory factors for obtaining a signed DNAR order were a multiprofessional approach to the care of palliative care patients, a good working relationship between GP and district nurse, the GP and district nurse working from the same premises and district nurse confidence in commencing the LCP. Inhibitory factors were initial GP ambivalence towards the LCP, ambivalence of the district nurse to completing the LCP process, difficulties with accessing a GP to sign the DNAR order and commencing the LCP out of hours.

Conclusions The study demonstrates the importance of a co-ordinated multi-professional approach to achieve a signed DNAR order of the LCP. It highlights the need for the on-going education of healthcare professionals on end of life issues.

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