Key stakeholders' experiences and views of the NHS End of Life Care Programme: findings from a national evaluation

The role of service factors on variations in place of death: an observational study

Background

Previous studies have revealed that there is significant geographical variation in place of death in (PoD) England, with sociodemographic and clinical characteristics explaining ≤ 25% of this variation. Service factors, mostly modifiable, may account for some of the unexplained variation, but their role had never been evaluated systematically.

Methods

A national population-based observational study in England, using National Death Registration Database (2014) linked to area-level service data from public domains, categorised by commissioning, type and capacity, location and workforce of the services, and the service use. The relationship between the service variables and PoD was evaluated using beta regression at the area level and using generalised linear mixed models at the patient level. The relative contribution of service factors at the area level was assessed using the per cent of variance explained, measured by R2. The total impact of service factors was evaluated by the area under the receiver operating characteristic curve (AUC). The independent effect of service variables was measured at the individual level by odds ratios (ORs).

Results

Among the 431,735 adult deaths, hospitals were the most common PoD (47.3%), followed by care homes (23.1%), homes (22.5%) and hospices (6.1%). One-third (30.3%) of the deaths were due to cancer and two-thirds (69.7%) were due to non-cancer causes. Almost all service categories studied were associated with some of the area-level variation in PoD. Service type and capacity had the strongest link among all service categories, explaining 14.2–73.8% of the variation; service location explained 10.8–34.1% of the variation. The contribution of other service categories to PoD was inconsistent. At the individual level, service variables appeared to be more useful in predicting death in hospice than in hospital or care home, with most AUCs in the fair performance range (0.603–0.691). The independent effect of service variables on PoD was small overall, but consistent. Distance to the nearest care facility was negatively associated with death in that facility. At the Clinical Commissioning Group level, the number of hospices per 10,000 adults was associated with a higher chance of hospice death in non-cancer causes (OR 30.88, 99% confidence interval 3.46 to 275.44), but a lower chance of hospice death in cancer causes. There was evidence for an interaction effect between the service variables and sociodemographic variables on PoD.

Limitations

This study was limited by data availability, particularly those specific to palliative and end-of-life care; therefore, the findings should be interpreted with caution. Data limitations were partly due to the lack of attention and investment in this area.

Conclusion

A link was found between service factors and PoD. Hospice capacity was associated with hospice death in non-cancer cases. Distance to the nearest care facility was negatively correlated with the probability of a patient dying there. Effect size of the service factors was overall small, but the interactive effect between service factors and sociodemographic variables suggests that high-quality end-of-life care needs to be built on service-level configuration tailored to individuals’ circumstances.

Future work

A large data gap was identified and data collection is required nationally on services relevant to palliative and end-of-life care. Future research is needed to verify the identified links between service factors and PoD.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

Background: The Liverpool Care Pathway for the Dying Patient ('LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review.  Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the 'boundary object' concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.

The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

Background: The Liverpool Care Pathway for the Dying Patient ('the LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review.  The ensuing debate among clinicians polarised between 'blaming' of the LCP and regret at its removal. Employing the concept of 'boundary objects', we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP 'scandal' demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care.  Conclusions:  In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.

Interventions at the end of life - a taxonomy for 'overlapping consensus'

Context: Around the world there is increasing interest in end of life issues. An unprecedented number of people dying in future decades will put new strains on families, communities, services and governments.  It will also have implications for representations of death and dying within society and for the overall orientation of health and social care. What interventions are emerging in the face of these challenges? Methods: We conceptualize a comprehensive taxonomy of interventions, defined as 'organized responses to end of life issues'. Findings: We classify the range of end of life interventions into 10 substantive categories: policy, advocacy, educational, ethico-legal, service, clinical, research, cultural, intangible, self-determined. We distinguish between two empirical aspects of any end of life intervention: the 'locus' refers to the space or spaces in which it is situated; the 'focus' captures its distinct character and purpose. We also contend that end of life interventions can be seen conceptually in two ways - as 'frames' (organized responses that primarily construct a shared understanding of an end of life issue) or as 'instruments' (organized responses that assume a shared understanding and then move to act in that context). Conclusions: Our taxonomy opens up the debate about end of life interventions in new ways to provide protagonists, activists, policy makers, clinicians, researchers and educators with a comprehensive framework in which to place their endeavours and more effectively to assess their efficacy. Following the inspiration of political philosopher John Rawls, we seek to foster an 'overlapping consensus' on how interventions at the end of life can be construed, understood and assessed.

An Integrated Literature Review of Death Education in Pre-Registration Nursing Curricula: Key Themes

Recent policy has raised the profile of end-of-life care internationally, with the aim of increasing access to quality care for everyone experiencing life-limiting illness. This reflects an international shift in the provision of palliative care to encompass chronic conditions other than cancer. Nurses have an important role in delivering this care and need to be equipped with particular knowledge and skills. However, pre-registration nursing curricula have traditionally had a limited emphasis on death and dying and nurses report feeling unprepared to care for dying patients. This has led to claims that death education in pre-registration curricula is inadequate. This integrated review explores the published literature that reports on death education within pre-registration nurse education. Presenting an international overview, the aim of the review is to contribute to knowledge about the nature and extent of death education in pre-registration curricula. In the context of this paper, death education encompasses both palliative and end-of-life care. Electronic searches of major bibliographic databases found inconsistencies across educational provision with variations in quantity, content, and approach. Despite an increasing amount of death education in pre-registration curricula, there remains a deficit in key areas such as knowledge, skills, organisation of care, and teamwork.

Systematic realist review of key factors affecting the successful implementation and sustainability of the Liverpool care pathway for the dying patient

BACKGROUND

The Liverpool Care Pathway (LCP) is recommended internationally as a best practice model for the care of patients and their families at the end of life. However, a recent national audit in the United Kingdom highlighted shortcomings; and understanding is lacking regarding the processes and contextual factors that affect implementation.

AIM

To identify and investigate factors that help or hinder successful implementation and sustainability of the LCP.

METHODS

Electronic databases (Medline, CINAHL, British Nursing Index, Science Direct) and grey literature were searched, supplemented by citation tracking, in order to identify English language papers containing information relevant to the implementation of the LCP. Using a realist review approach, we systematically reviewed all relevant studies that focused on end of life care and integrated care pathway processes and identified theories that explained how the LCP and related programmes worked.

RESULTS

Fifty-eight papers were included in the review. Key factors identified were: a dedicated facilitator, education and training, audit and feedback, organisational culture, and adequate resources.

DISCUSSION

We discuss how these factors change behaviour by influencing the beliefs, attitudes, motivation and confidence of staff in relation to end of life care, and how contextual factors moderate behaviour change.

CONCLUSIONS

The implementation process recommended by the developers of the LCP is necessary but not sufficient to ensure successful implementation and sustainability of the pathway. The key components of the intervention (a dedicated facilitator, education and training, audit and feedback) must be configured to influence the beliefs of staff in relation to end of life care, and increase their motivation and self-efficacy in relation to using the LCP. The support of senior managers is vital to the release of necessary resources, and a dominant culture of cure, which sees every death as a failure, works against effective communication and collaboration in relation to the LCP.

Information management and quality of palliative care in general practices: Secondary analysis of a UK study

Palliative care seeks to improve quality of life for patients with terminal, chronic or life-long, illnesses. In the UK, most palliative care occurs in primary care, for example, through general practices. A recent national UK survey of palliative care within general practices concluded that practices that utilized recognized initiatives to promote palliative care demonstrated better clinical care and higher perceived quality of palliative care. This paper reports on secondary analyses from that survey to investigate the management of information related to palliative care within practices. Relatively high levels of information provision to families and carers were reported, over two-thirds of practices reported having unified records for palliative care patients and over 90% of practices reported having a cancer/palliative care register that was fully or mostly operational. Larger practices, those using the Gold Standards Framework and practices using unified record keeping for palliative care, were independently more likely to give information to families and carers and were more likely to have a mostly or fully operational palliative care register. When testing for the relationship between measures of the structures and processes of information management and the perceived quality of care, as an outcome, within the practices, practices with a fully operational palliative care register and practices that had higher scores on the record-keeping scale were more likely to rate the quality of their palliative care as very good.

Perceived risks around choice and decision making at end-of-life: a literature review

BACKGROUND

the World Health Organization identifies meeting patient choice for care as central to effective palliative care delivery. Little is known about how choice, which implies an objective balancing of options and risks, is understood and enacted through decision making at end-of-life.

AIM

to explore how perceptions of 'risk' may inform decision-making processes at end-of-life.

DESIGN

an integrative literature review was conducted between January and February 2010. Papers were reviewed using Hawker et al.'s criteria and evaluated according to clarity of methods, analysis and evidence of ethical consideration. All literature was retained as background data, but given the significant international heterogeneity the final analysis specifically focused on the UK context.

DATA SOURCE

the databases Medline, PsycINFO, Assia, British Nursing Index, High Wire Press and CINAHL were explored using the search terms decision*, risk, anxiety, hospice and palliative care, end-of-life care and publication date of 1998-2010.

RESULTS

thematic analysis of 25 papers suggests that decision making at end-of-life is multifactorial, involving a balancing of risks related to caregiver support; service provider resources; health inequalities and access; challenges to information giving; and perceptions of self-identity. Overall there is a dissonance in understandings of choice and decision making between service providers and service users.

CONCLUSION

the concept of risk acknowledges the factors that shape and constrain end-of-life choices. Recognition of perceived risks as a central factor in decision making would be of value in acknowledging and supporting meaningful decision making processes for patients with palliative care needs and their families.

Tracking the route to sustainability: a service evaluation tool for an advance care planning model developed for community palliative care services

AIMS AND OBJECTIVES

The study aim was to develop a service evaluation tool for an advance care planning model implemented in community palliative care.

BACKGROUND

Internationally, advance care planning programmes usually measure success by completion rate of advance directives or plans. This outcome measure provides little information to assist nurse managers to embed advance care planning into usual care and measure their performance and quality over time. An evaluation tool was developed to address this need in Australian community palliative care services.

DESIGN

Multisite action research approach.

METHODS

Three community palliative care services located in Victoria, Australia, participated. Qualitative and quantitative data collection strategies were used to develop the Advance Care Planning-Service Evaluation Tool.

RESULTS

The Advance Care Planning-Service Evaluation Tool identified advance care planning progress over time across three stages of Establishment, Consolidation and Sustainability within previously established Model domains of governance, documentation, practice, education, quality improvement and community engagement. The tool was used by nurses either as a peer-assessment or self-assessment tool that assisted services to track their implementation progress as well as plan further change strategies.

CONCLUSION

The Advance Care Planning-Service Evaluation Tool was useful to nurse managers in community palliative care. It provided a clear outline of service progress, level of achievement and provided clear direction for planning future changes.

RELEVANCE TO CLINICAL PRACTICE

The Advance Care Planning-Service Evaluation Tool enables nurses in community palliative care to monitor, evaluate and plan quality improvement of their advance care planning model to improve end-of-life care. As the tool describes generic healthcare processes, there is potential transferability of the tool to other types of services.

Advance care planning for cancer patients in primary care: a feasibility study

BACKGROUND

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

AIM

To assess the feasibility of implementing advance care planning in UK primary care.

DESIGN OF STUDY

Mixed methods evaluation of a pilot educational intervention.

SETTING

Four general practices in south-east Scotland.

METHOD

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

RESULTS

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a 'good death'. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of 'tick-box' approach. Following the workshop, participants' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

CONCLUSION

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.

Planning training seminars in palliative care: a cross-sectional survey on the preferences of general practitioners and nurses in Austria

BACKGROUND

Training in palliative care is frequently requested by health care professionals. However, little is known in detail about the subject matters and the educational preferences of physicians and staff or assistant nurses in this field.

METHODS

All 897 registered GPs and all 933 registered home care nurses in the district of Steiermark/Austria were sent postal questionnaires.

RESULTS

Results from 546 (30%) respondents revealed that GPs prefer evening courses and weekend seminars, whereas staff and assistant nurses prefer one-day courses. Multidisciplinary sessions are preferred by almost 80% of all professional groups. GPs preferred multi disciplinary groups most frequently when addressing psychosocial needs (88.8%) and ethical questions (85.8%). Staff and assistant nurses preferred multidisciplinary groups most frequently in the area of pain management (88%) and opted for multi disciplinary learning to a significantly higher extent than GPs (69%; p < 0.01). Those topics were ranked first which are not only deepening, but supplementing the professional training. On average, GPs were willing to spend a maximum amount of euro 400 per year for training seminars in palliative care, whereas nurses would spend approximately euro 190 for such classes.The results provide a detailed analysis of the preferences of GPs and nurses and offer guidance for the organisation of training seminars in palliative care.

CONCLUSIONS

Medical and nursing education programs often pursue separate paths. Yet our findings indicate that in palliative care multidisciplinary training seminars are favoured by both, doctors and nurses. Also, both groups prefer topics that are not only deepening, but supplementing their professional knowledge.