End of Life Care Pathway
The end of life care pathway provides a structured framework for delivering individualised care in the last days and hours of life, replacing the Liverpool Care Pathway with personalised care planning as recommended by NICE NG31.
Key Facts
The Liverpool Care Pathway (LCP) was withdrawn in 2014 following the Neuberger Review (More Care, Less Pathway) due to concerns about poor implementation NICE NG31 (2015) replaced LCP with recommendations for individualised care of the dying adult Five Priorities of Care for the dying person (Leadership Alliance for the Care of Dying People): recognise, communicate, involve, address needs of those important to them, create an individualised plan Recognising dying is a clinical decision; should be made by the senior responsible clinician and communicated to patient, family, and team Anticipatory prescribing should be in place for: pain, agitation, secretions, nausea/vomiting Regular review: at least daily reassessment; consider whether the person is improving (may need to de-escalate dying pathway) Hydration and nutrition: assess individually; not routinely started or withdrawn; based on patient benefit and wishes After death: sensitive care of the body; verification and certification of death; family support; bereavement services
Overview
Key Facts
The end of life care pathway is a framework, not a checklist. It must be delivered with compassion, individualised to each patient, and regularly reviewed.
Epidemiology
- ~500,000 deaths/year in England
- Approximately 30% of hospital deaths are expected
- Most dying patients spend their last days in hospital (~46%), home (~25%), or care home (~22%)
Aetiology
The pathway applies to patients recognised as dying from any cause.
Pathophysiology
Not a pathological process. The pathway addresses the care needs of people in the last days of life.
Clinical Presentation
Recognising Dying
- Progressive deterioration not responding to treatment
- Reduced consciousness, bedbound
- Taking only sips of fluid or nil by mouth
- Reduced urine output
- Peripheral cyanosis, mottling
- Changes in breathing (Cheyne-Stokes, irregular)
- Cold peripheries
NICE NG31 — What to Do
- Recognise that the person may be dying
- Communicate sensitively with the dying person and those important to them
- Involve the dying person and those close to them in decisions about their care
- Address the needs of families and carers
- Develop an individualised plan of care
Red Flags
- Uncertainty about whether patient is dying (seek senior opinion)
- Reversible cause of deterioration not excluded
- Family disagreement about care goals
- Patient distress not controlled
- Staff distress or moral injury
Differential Diagnosis
| Scenario | Action |
|---|---|
| Dying confirmed | Individualised care plan; anticipatory medications |
| Uncertain if dying | Continue active treatment AND prepare for possible dying; reassess daily |
| Improving after being considered dying | De-escalate; restart appropriate oral medications and hydration |
Diagnosis / Investigation
Bedside
- Clinical assessment (as above)
- Review all medications: stop non-essential; ensure anticipatory medications prescribed
- Assess symptom burden
- Assess patient's wishes and preferences
- Spiritual/religious needs
Bloods
- Generally NOT appropriate if patient is dying
- Only if result would change management (e.g. correctable hypercalcaemia)
Imaging
- NOT appropriate in dying phase
Special Tests
- Review advance directives, ADRT, ReSPECT form
- Verify DNACPR status
Management
Non-pharmacological
- Individualised care plan: documented within hours of recognising dying
- Communication: honest, compassionate conversations with patient and family
- Comfort care: mouth care (every 2 hours), eye care, skin care, repositioning
- Environment: quiet, private, comfortable; unrestricted visiting; personal belongings
- Stop non-essential: monitoring, routine observations, blood tests, inappropriate medications
- Spiritual care: chaplaincy, religious observances as wished
- Family support: keep informed, involve in care, prepare for death
- After death: verification of death, care of the body, death certification, family support, bereavement services
Pharmacological
- Anticipatory prescribing (PRN medications available):
- Pain: morphine 2.5-5mg SC PRN 1-hourly
- Agitation: midazolam 2.5-5mg SC PRN 1-hourly
- Secretions: hyoscine butylbromide 20mg SC PRN 1-hourly (or glycopyrronium 200mcg)
- Nausea: haloperidol 0.5-1mg SC PRN or levomepromazine 6.25mg SC PRN
- Syringe driver: if regular SC doses needed
- Review hydration: clinically assisted hydration (IV/SC) assessed individually; not routinely started or stopped
- Stop non-essential medications: antihypertensives, statins, anticoagulants (unless for symptom control), PPIs, supplements
Surgical/Interventional
- Not appropriate in dying phase
- Palliative procedures (urinary catheter for retention) may be appropriate for comfort
Referral Criteria
- Complex symptoms: specialist palliative care
- Family unable to cope: additional support, social services
- Staff distress: debrief, peer support
- After death: bereavement services
Prognosis
- Median survival after recognition of dying: 1-3 days
- Prognostication in last days is difficult but important for planning
- Good end of life care improves quality of death for patient and bereavement outcomes for family
- Approximately 70% of patients prefer to die at home; achieving this requires forward planning
Other Relevant Information
Neuberger Review Findings (2013)
| Issue with LCP | Lesson |
|---|---|
| Tick-box mentality | Individualise care |
| Poor communication | Communicate honestly and sensitively |
| Inappropriate withdrawal of food/fluid | Assess individually |
| Premature diagnosis of dying | Regularly reassess; accept uncertainty |
| Lack of senior oversight | Senior clinician makes dying diagnosis |
NICE NG31 — Priorities for Care of the Dying Person
| Priority |
|---|
| 1. Recognise that the person may be dying |
| 2. Communicate sensitively with the dying person and those important to them |
| 3. Involve them in decisions |
| 4. Address the needs of families |
| 5. Create an individualised plan |