Patient Pathways of Care in Adult Nursing

Patient Pathways of Care in Adult Nursing

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22 May 2017


Patient pathways, also referred to as care paths, case management plans, integrated care pathways, or clinical care pathways, are used in clinical nursing to systematically plan and follow up on a client care programme-focused patient. The Centre for Policy on Ageing (CPA) pointed out that patient pathways are used to map out the care journey a person should follow and prompt for care (CPA, 2014). In addition, patient pathways are a means of establishing a process of best practice that must be followed to provide treatment to a patient with a specific condition or needs. The rationale for using care pathways is to create a consistent standard of documentation that is applied to provide the basis for an on-going health audit. The intentions of an integrated care pathway (ICP) are to act as a guide for treatment and a framework for documenting a client’s patient’s progress (CPA, 2014). They are a multidisciplinary tool used in nursing to improve the quality and efficiency of evidence-based practice and also as a communication tool. The purpose of this paper is to explore the pathway of end-of-life care (EOLC), provide a justification of the pathway with reference to national and local agendas, analyse the assessment strategies utilised within the selected pathway, and offer an assessment of the patients on how the pathway impacts the care planning process.

The Case Study

In this case study, all the names have been changed as part of ethical considerations in order to ensure the privacy and confidentiality of the people. Kay is a 33-year-old female, married to Richard, and they have five children. In 2015, Kay was diagnosed with invasive ductal cancer and micropapillary cancer of the right breast. Chemotherapy was stopped after 5 cycles due to toxicity. It was then decided that Kay should be offered two separate drug trials at two leading London hospitals. Kay had a relapse in late 2016 when a stent was inserted due to superior vena cava obstruction (SVCO). In March 2017, Kay was admitted to the hospice awaiting a plural drain due to a right-sided malignant plural effusion with increasing breathlessness. Symptom control was the main agenda for admission with possible end-of-life care. The Braden scale/bio score increased greatly due to Kay’s rapid decline in pressure risk. Kay has a pain pump implant, but her pain score is increasing as a result of anxiety and pain. On a pain scale of 1–10, the pain was a constant 4, and she did not require medications in the last few days. The emergency discharge/ssocial worker wants Kay to go to her mom’s house, as she already takes care of herself and stays 24 hours a day. However, this has caused problems between mom and Kay’s husband, and subsequently, Kay does not feel she can cope with the children in terms of providing care to them. 

End of Life Care (EOLC) 

Persons with terminal disease or at the end of life require care and support that is personalised and coordinated around the health, social, and emotional needs of the person and family members. According to the NHS (2017), people who are near death are supported through the use of EOLC. The Royal College of Nursing (RCN, 2017) states that “end-of-life care is not just the responsibility of specialist nurses and teams, but rather that everyone should be able to care for a loved one as they reach the end of their lives, including all nurses and health care support workers in all settings, the patient’s family, as well as members of the community” (p. 1). The EOLC is provided to help a person live well until death and possibly die with dignity. As the responsibility of a specialist, EOLC ensures that the wishes and preferences of patients at the end of life are met. Support is also provided to the carers, family members, and other important ant people. A patient has the right to express her wishes with regard to the care needed. The NHS (2017) contends that EOL is not just the technical and practical delivery of care provided to a dying person but also the support and information provided both to the person and the people around the client. The RCN (2017) believes that every person has the right to be cared for by others with respect and dignity at the end of their lives.

End-of-life care entails providing palliative care to patients with an illness that cannot be easily cured. The aim of palliative care is to make a patient like Kay as comfortable as possible through paid management and other distressing symptoms (Chan, Webster, & Bowers, 2016; NHS, 2017). The most appropriate pathway associated with the EOLC is the Liverpool Care Pathway (LCP). Developed at the Royal Liverpool University Hospital in collaboration with the Marie Curie Palliative Care Institute (MCPCI), the LCP was designed to offer the best possible quality of care needed by dying patients during their last days and hours of life (NHS, 2015). According to CPA (2014), “Developed from a model of care successfully used in hospices, the Liverpool Care Pathway for the Dying Patient (LCP) is a generic approach to care for the dying, intended to ensure that uniformly good care is given to everyone thought to be in the final stages before death” (p. 5). The approach is suitable for the case of Kay because it ensures that a peaceful and dignified death is achieved. In addition, the EOLC is regarded as the best standard not only in the UK but in the world (NHS, 2015). If used properly, the LCP would allow patients to die a peaceful and dignified death, although its implementation is sometimes linked with poor care.

The LCP, which is a framework for good practice, was withdrawn recently following concerns about the quality of care offered to some people. In June 2014, the Department of Health (DH) announced the adoption of a new approach to caring for people in their last days of life, which is an individualised EOLC (House of Parliament, 2014). Developed by the Leadership Alliance for the Care of Dying People (LACDP), the pathway is based on five priorities of care based on the person’s wishes and preferences (LACDP, 2014). The new pathway entails psychological, social, and spiritual support for the patient and her family. Such a pathway is holistic in nature because it deals with the client as a “whole” person (Cauldwell & Stone, 2015). Thus, the improved LCP, which is the LACDP’s EOLC pathway, was selected for the current placement experience in order to analyse the assessment and care planning process. 

Justification of the Pathway 

Micropapillary breast carcinoma, also referred to as invasive micropapillary carcinoma (IMPC), represents 6% of all breast cancers. The early detection of this type of cancer is important because, when treatment is started early, the impact could be prevented. In comparison to invasive ductal carcinoma, the IMPC has a high propensity for metastatic spread, with reported rates of 46–95% (Yamaguchi et al., 2010). Thus, it has a worse prognosis and lower survival rates. Given that Kay’s cancer has already reached a stage where she needs to be admitted to hospice, the EOLC pathway is effective as part of EOL. 

The National End of Life Strategy (DH 2008) has developed an EOL pathway that has six steps needed to provide good EOLC. The first step is discussion of the EOL approaches; the second is assessment and care planning; the third is coordination of care; the fourth is delivery of high-quality services in a care home; the fifth is care during the last days of life; and step six is care after death (Skills for Care, 2013). The priorities accorded to the patients under the LACDP’s EOLC pathway must meet the Nice Quality Standard for EOLC. For example, the five priorities for the care of the dying person have to be provided in an effective, person-centred, and safe way, regardless of the care setting. Thus, the selected policy is in line with the national and local agenda because it encourages the delivery of safe and person-based EOLC (LACDP, 2014). The priorities are: (a) clear recognition and communication of actions and decisions; (b) sensitive communication between the dying person and staff; (c) shared decision-making; (d) identification of family member needs and those of others; and (e) application of an individual plan of care (Cauldwell & Stone, 2015). Additionally, the national recommendations and published evidence advocate the provision of care plans to every person and carer (Birmingham CrossCity, 2014). In addition, the pathway corresponds to the NHS Outcomes Framework, which advocates for quality of life for people with long-term conditions, assistance to persons to recover, ensuring people are experienced, and treating and caring for people in a safe EOLC. 

The model selected is also in line with the Mental Capacity Act of 2005. The Act is the centre for making decisions for persons in EOL because, at that stage, they could be mentally challenged people. Manchester City Council (2010) contended that the Act “provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves” (p. 1). The underlying philosophy of the ACT is to ensure that any decisions that are made and the actions taken by someone else on behalf of one lacking the capacity to make decisions are made in their best interests. For instance, when making decisions related to Kay, the EOLC ensures that the capacity of the patient is considered in terms of making and understanding specific decisions by herself (Manchester City Council, 2010). 

Biopsychosocial Perspective

The biopsychosocial perspective is composed of biological, social, and psychological assessments of the whole person (Disorbio, Bruns, & Barolat, 2006). The End of Life Care Strategy chosen recognises the significance of undertaking a holistic assessment that covers the social, psychological, and biological needs of the patient. The strategy, according to the NHS (2011), stresses the importance of treating patients as individuals, supporting them when making choices and decisions about care, and assessing patients’ needs, priorities, and preferences. The social and occupational well-being assessment is undertaken in order to establish the general situation of the patient (Kay), ascertain the current support provided, and determine if additional support needs to emerge. To establish the social and occupational well-being of the patient, the assessor could use a survey tool on the patient and the people around them to establish their social needs. The Social Work Assessment Tool (SWAT) could be used to establish social support, death anxiety, denial, and end-of-life decisions (Reese et al., 2006). 

The psychological assessment is related to the Level 1 psychological assessment that is recommended under NICE’s guidance on palliative care and support for adults with cancer (NHS, 2011). A psychological assessment is required in the case of Kay in order to establish the history of the problem, its personal impact on her as a person and on others, such as family members, and ascertain the available strategies that can be used to promote self-care for the disease. The assessor is expected to use their professional judgement in order to establish the psychological needs and support required. Personal judgement is an effective way because it promotes person-centred care for the patient. Psychological support could comprise general emotional support and psychological care. Psychological interventions that are applicable include cognitive behaviour therapy and medication to ease psychological distress, depression, and anxiety in the patient. The numerical rating scales could be used to establish the psychological issues that require psychological interventions. 

Biological assessments are undertaken to establish the changes in the body that are associated with the disease. Areas that are assessed include the heartbeat rate, pressure, stool, cancer stage, and pain levels. Biological assessments are undertaken in the laboratory, therefore, to establish the risk the patient is at and what medication could help the patient while at EOLC (NHS, 2011). The Braden scale/bio score could be used to assess pressure risk, while the Breast Cancer Risk Assessment Tool is applicable because it focuses on personal history and reproductive history to estimate the risk of the patient and those around her. 

Assessment and Impact to Care Planning

According to CPA, “all people approaching the end of life need to have their needs assessed, their wishes and preferences discussed, and an agreed set of actions reflecting the choices they make about their care recorded in a care plan” (Saunders, 2008, p. 13). In this case, the planning process entailed the assessment of Kay’s needs while she was in hospice awaiting a plural drain due to a right-sided malignant plural effusion with the intent of admission with a possible EOLC. In regard to the case of Kay, she was in a position to make an advance decision and to accept treatment. As noted by CPA (2014), her wishes and preferences about how she would be cared for and issues related to how she would like to die were also considered. This is in line with the LACDP’s EOLC pathway, which encourages the delivery of safe and person-based EOLC (LACDP, 2014). Subsequently, all her needs were to be incorporated into the care plan. Additionally, the care plan has to be reviewed by the multidisciplinary team, the carers, and the patient in order to establish areas that could be improved or where the patient wishes to change (Saunders, 2008). The planning processes in this case refer to achieving priorities of care. 

In addition, in case Kay is not in a position to make decisions, her mother, children, or husband could help in decision-making. In the case of Kay, she prefers to be cared for at the hospice and not at home. Nonetheless, she would like to be cared for and surrounded by family members who can provide emotional and spiritual support. According to the National Council for Palliative Care (2014), the rationale for Kay to let people know about her wishes is to provide her with a chance to discuss her views with her family members and carers. In addition, if Kay refuses to receive specific treatment, it is her responsibility to inform the people involved in her care. When making decisions about herself, the MCA 2005 was considered to ensure that her rights, individual values, attitudes, and beliefs are protected (Coggon & Miola, 2011). 

The assessments of the patients on the EOLC pathway impact the care planning process because they ensure that various symptoms are checked and managed appropriately. The pain of the patient must be established based on a pain scale of 1–10 to establish whether drugs should be provided or not. For instance, Kay has a moderate pain level of 4, and this prevents her from performing any duties or chores. Although she has not been on pain management, painkillers for her could be provided. The NHS (2015) contended that an assessment must be undertaken to discover how much pain she is in. In addition, she should be asked to choose the most suitable way in which she could use her painkillers. In addition, assessment of threats is important to ensure effective management of breathlessness. The NHS (2015) contended that breathlessness among patients in EOL results from treatable problems, including fluid-filled lungs, and that immediate treatment when provided could help. The cause of breathlessness in the case of Kay was not established immediately, but the reason for admission was to relieve breathlessness. 

Interestingly, there are challenges linked to the identification of EOLC needs, and assessment would play a major role in ensuring needs are established and necessary communications made. Findings have shown that disease trajectories are sometimes unpredictable, and it could be hard for clinicians to identify the period when a patient is nearing EOL (Addicott, 2010). In some cases, the professionals could feel unable to make a confident prognosis and communicate with the patient and their family members. In such a case, the EOLC pathway plays an integral role because it requires the disclosure of information to the patient in order to promote safe and dignified EOLC. Subsequently, gathering information could be effective in developing an agreed care plan using the revised Liverpool Care Pathway (or equivalent) with the aim of organising care in the last days of life. Effective communication is necessary to ensure that information is shared between the patient, family members, carers, and people around her. 

By assessing cognitive state, holistic common assessment in the case of Kay could highlight issues that concern her mental capacity. This is necessary to ensure that she can fully participate in decision-making and take the Act the Act into account in order to promote best-interest decisions. The assessment is thus important to provide person-centred care and meet Kay’s needs and her preferences for care. According to the NHS (2011), the end-of-life care strategy is important for carrying out a holistic assessment because it covers the psychological, physical, social, environmental, cultural, spiritual, and financial needs of the patient. The strategy is important in the case of Kay because it would ensure that she is treated as an individual, her needs are assessed, preferences and priorities established, and support provided to make choices about care and to agree on the most effective care plan. Holistic assessment is applicable in the identification of Kay’s unmet needs, such as her emotional and spiritual needs. A unified approach to holistic assessment is also an effective way that can be used to create opportunities for the person to consider, together with those involved in their care, and establish all aspects that affect their life. 


The EOLC is a responsibility of everyone, and it is used to provide care for a loved one when a person needs death or is nearing the is nearing the end of life. The EOLC is necessary for persons with terminal diseases, such as cancer, because such a person has the right to be cared for with respect and dignity during the EOL. The LCP pathway is a commonly used patient pathway, and when well used, it ensures dignified death. The LACDP’s EOLC pathway was selected for the current placement experience because it incorporates psychological, social, and spiritual support for the patient and her family.

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