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The Wales perspective of using an ICP for the last days of life

At today’s Care Pathways conference in London Dr Helen Mitchell and Dr Marlise Poolman National leads, Welsh Collaborative Care Priorities Project presented their work on the all-Wales Integrated Care Priorities for the Last Days of Life; discussing background and benchmarking,  reflections on the current all-Wales feedback mechanism, and providing (and evidencing?) individualised care.

The full presentation is available to download at the end of this page.


The Integrated Care Pathway for the last days of life was implemented on an all-Wales basis in 2000. In 2010 a major overhaul of the document was undertaken to simplify documentation and, early in 2012, further amendments were made to the tool, primarily to clarify issues around sedation, hydration and prescribing. To emphasise the importance of individual variation, the tool was renamed the Integrated Care Priorities (ICP) for the last days of life. The current ICP is now used throughout Wales by staff in district general hospitals and tertiary centres, community hospitals, hospices, specialist in-patient units, nursing homes and community nursing teams. 

If a goal in the ICP is not achieved, a variance is recorded and subsequently reported on the variance sheet within the ICP. Centralised collection and analysis of the variance sheets is a key feature of the Welsh ICP, which facilitates continuous quality monitoring and dynamic feedback to users. Since 2000 the centralised collection, analysis and feedback of variance sheets has registered 29,700 entries. Each entry represents one patient receiving end of life care through the ICP in a variety of care settings. 

Twice yearly benchmarking meetings are held in 3 regional sites. This provides opportunity for the project team to demonstrate trends in variance reporting and comparison between different user groups. The introduction of a revised ICP in Wales and the adverse publicity surrounding the Liverpool Care Pathway in England has not resulted in a reduction of variance sheet returns for analysis. The variances themselves remain the same and concern the management of pain, agitation and excess respiratory secretions at the end of life. However, variance recording and reporting remains an issue for on-going training and education. During benchmarking meetings, feedback from users on ICP use and documentation are encouraged, as well as discussion / reflection on local clinical practices and developments.

An annual audit of ICP use is also carried out by the WCCPP project team. The 2013 audit showed an overall improvement of the use of the document, notably, religious/spiritual support. The combination of regular benchmarking and annual audit informs the annual updates and revisions of the ICP. 

Over the past thirteen years, the availability of a project team to support the implementation and use of the ICP to deliver end of life care has also resulted in the development of a robust network across the palliative care community in Wales. The ability of that network to respond to changes in the ICP tool has been demonstrated by the sustained return of variance sheets for analysis. More recently, this network has been instrumental in clarifying the future direction for the ICP in Wales by providing a national mandate to continue its use as an important tool in end of life care. 

The WCCPP team has several challenges ahead 

  • to improve understanding and quality of variance reporting
  • to seek alternative methods of ICP data collection (including qualitative and quantitative measures)
  • to include the carer experience within our research agenda
  • to evidence the effectiveness of the ICP in delivering end of life care

Dr Helen Mitchell is Consultant in Palliative Medicine, Betsi Cadwaladr University Health Board and Dr Marlise Poolman is Senior Clinical Lecturer Palliative Medicine, Bangor University 

Forthcoming events of interest:

Clinical Audit for Improvement 2014
Wednesday 26 February 2014 — Thursday 27 February 
Hallam Conference Centre

Patient Experience Insight: Demonstrating Responsiveness to Feedback
Monday 28 April 2014 
ICO Conference Centre

Action Planning
Wednesday 30 April 2014 
Hallam Conference Centre

Masterclass: Service Innovation and Improvement
Tuesday 20 May 2014 
BPP Law School

Measuring and Monitoring Quality
Wednesday 21 May 2014 
Colmore Gate Conference Centre

Clinical Audit Masterclass
Thursday 22 May 2014 
Hallam Conference Centre

Implementing the Named Responsible Doctor and Nurse in Hospital
Wednesday 11 June 2014 
ICO Conference Centre

Download: Dr Mitchell & Dr Poolman full presentation

12 February 2014


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