The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

Dying in hospital in Germany - optimising care in the dying phase: study protocol for a multi-centre bottom-up intervention on ward level

Background

Hospitals are globally an important place of care for dying people and the most frequent place of death in Germany (47%), but at the same time, the least preferred one – for both patients and their relatives. Important indicators and outcome variables indexing quality of care in the dying phase are available, and various proposals to achieve corresponding quality objectives exist. However, they are not yet sufficiently adapted to the heterogeneous needs of individual hospital wards.

Methods

This multi-centre single-arm pre-post study aims at the development and implementation of context-specific measures in everyday clinical practice, followed by evaluating this approach. Therefore, (1) already existing measures regarding optimal care in the dying phase are identified applying a systematic literature review as well as an online survey and a symposium with experts. Supported by the thereby generated collection of measures, (2) a stratified sample of ten teams of different wards from two university hospitals select suitable measures and implement them in their everyday clinical practice. Circumstances of patients’ deaths on the selected wards are recorded twice, at baseline before application of the self-chosen measures and afterwards in a follow-up survey. Retrospective file analysis of deceased persons, quantitative staff surveys as well as qualitative multi-professional focus groups and interviews with relatives form the data basis of the pre-post evaluation. (3) Results are reviewed regarding their transferability to other hospitals and disseminated (inter-)nationally.

Discussion

Measures that are easy to implement and appropriate to the specific situation are supposed to significantly improve the quality of care during the dying phase in hospitals and contribute to the well-being of dying patients and their relatives. Successful implementation of those measures requires consideration of the individual conditions and needs of patients and their relatives—but also of the health professionals—on the different hospital wards. Therefore, a bottom-up approach, in which the ward-specific situation is first analysed in detail and then the staff itself selects and implements measures to improve care, appears most promising for optimising care in the dying phase in hospitals.

Trial registration

The study is registered in the German Clinical Trials Register (DRKS00025405).

Characteristics of patients with cancer in European long-term care facilities

Purpose

Up to 26% of residents in nursing homes (NHs) are affected by cancer. Their care represents a challenge, because NHs are not usually considered a setting focused on oncologic management and care. The aim of this paper is to describe socio-demographic and clinical features of patients with cancer residing in European NHs.

Methods

Cross-sectional study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. Participants were assessed through the interRAI-LTCF, which includes cancer assessment.

Results

Among 4140 participants (mean age 83.4 years; female 73%), 442 (10.7%) had cancer. Patients with cancer had a higher prevalence of do-not-resuscitate directives compared to those without cancer (21.1% vs 16.5%, p = 0.019). Variables directly associated with cancer were male sex (adj OR 1.67, 95% CI 1.36–2.05), pain (adj OR 1.43, 95% CI 1.16–1.77), fatigue (adj OR 1.25, 95% CI 1.01–1.55), polypharmacy (adj OR 1.59, 95% CI 1.21–2.08) and falls (adj OR. 1.30, 95% CI 1.01–1.67). Dementia was inversely associated with cancer (adj OR 0.74, 95% CI 0.58–0.94). Symptomatic drugs such as opioids (23.5% vs 12.2, p < .001), NSAIDS (7.2% vs 3.9%, p = 0.001), antidepressants (39.1% vs 33.8%, p = 0.026) and benzodiazepines (40.3% vs 34.3, p = 0.012) were all prescribed more in participants with cancer compared to those without cancer.

Conclusions

Cancer patients are prevalent in European NHs and they show peculiar characteristics. Studies are needed to evaluate the impact of a supportive care approach on the management of NHs residents with cancer throughout all its phases, until the end-of-life care

Periviable birth: A review of ethical considerations

BACKGROUND

Advances in perinatology and medical technology have pushed the limits of viability to unprecedented extremes, leading to a growing population of NICU "graduates" with a wide range of health issues. Although survival rates from 22 weeks of gestation onwards have improved over the last 30 years, the incidence of disabilities remains the same. Providing intensive care to a high-risk population with significant mortality and morbidity raises the fundamental conflict between sanctity and quality of life. Potential severe handicap and need for frequent tertiary care inevitably impact the whole family unit and may outweigh the benefit of survival. The aim of this study is to explore and summarize the ethical considerations in neonatal care concerning perivable birth.

METHODS

Eligible studies published on PubMed were included after a systematic search using the PICO methodology.

RESULTS

Forty-eight studies were systematically reviewed regarding guidelines, withholding or withdrawing treatment, parental involvement, and principles applied in marginal viability. As periviable birth raises an array of complex ethical and legal concerns, strict guidelines are challenging to implement.

CONCLUSIONS

Active life-sustaining interventions in neonatology should be balanced against the risk of putting infants through painful and futile procedures and survival with severe sequelae. More evidence is needed on better prediction of long-term outcomes in situations of imminent preterm delivery, while good collaboration between the therapeutic team and the parents for life-and-death decision-making is of utmost importance. HIPPOKRATIA 2021, 25 (1):1-7.

Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians' and nurse practitioners' perceptions

Background

The Liverpool care pathway for the dying patient (LCP) is a multidisciplinary tool developed for the dying phase for use in palliative care settings. The literature reports divergent experiences with its application in a nursing home setting related to its implementation and staff competencies. The aim of this study is to understand how the LCP is being used in the context of the nursing home, including for residents with dementia, and experienced from the perspectives of those responsible for medical treatment in nursing homes.

Methods

A mixed-methods approach was used, consisting of a survey followed by interviews. A link to a 9-item online survey with closed and open-ended questions was emailed to all physicians and nurse practitioners of 33 care organisations with nursing homes in three regions of the Netherlands (North, West and South). In addition, 10 respondents with particularly positive or negative experiences were selected for semi-structured interviews.

Results

The survey was completed by 159 physicians and nurse practitioners. The respondents were very positive on the content and less positive on the use of the LCP, although they reported difficulties identifying the right time to start the LCP, especially in case of dementia. Also using the LCP was more complicated after the implementation of the electronic health record. The LCP was judged to be a marker of quality for the assessment of symptoms in the dying phase and communication with relatives.

Conclusion

An instrument that prompts regular assessment of a dying person was perceived by those responsible for (medical) care to contribute to good care. As such, the LCP was valued, but there was a clear need to start it earlier than in the last days or hours of life, a need for a shorter version, and for integration of the LCP in the electronic health record. Regular assessments with an instrument that focusses on quality of care and good symptom control can improve palliative care for nursing home residents with and without dementia.

International transfer and translation of an end of life care intervention: the case of the Liverpool Care Pathway for the dying patient

We explore how and why the Liverpool Care Pathway (LCP) for the dying patient was transferred to 20 countries beyond the UK, and with what consequences for policy and practice. Our paper synthesises findings from 95 publications contained in a historical narrative literature review on the implementation of the LCP outside the United Kingdom, alongside data from 18 qualitative interviews with 19 key actors involved with the LCP in 14 countries. We use the review to explore the timelines and patterns of development and implementation in the specific countries, to consider what forms of research and evaluation about the LCP were undertaken to establish its effectiveness, and to summarise the resulting findings and their consequences. We use the interviews to gain insights into the elements, processes and dynamics that shaped the transfer and translation of the LCP from one location to another, across national boundaries. Using six questions from the policy transfer literature we then explain who were the key actors involved; what was transferred; from where lessons were drawn; the different degrees of transfer that took place; what restricted or facilitated transfer; and how transfer was related to 'success' or 'failure'. We conclude that the spread of the LCP took place mostly in prosperous countries, and was sustained over around 15 years.  It took in differing geographies and cultures, and a variety of linguistic, policy and practice contexts. If it did not succeed in a wider transformational goal, it appears to have been well received and perceived as beneficial in many contexts, largely avoiding accusations of mis-use and harm that had occurred in the UK, and in some cases fostering a sustained international collaboration and ongoing use of local variants, even after withdrawal in its country of origin in 2014.

Elderly gynaecological cancer patients at risk for poor end of life care: a population-based study from the Swedish Register of Palliative Care

Introduction: Poorer end-of-life (EOL) care for elderly cancer patients has been reported. We assessed the impact of age on 13 indicators for the quality of EOL care as well as adherence to 6 national quality indicators in gynaecological cancer patients.Methods: Age-dependent differences in 13 palliative care quality indicators were studied in gynaecological cancer patients registered in the population-based Swedish Register of Palliative Care. Association between the patient's age and each quality indicator was analyzed by logistic regression, adjusted for place of death where appropriate. Adherence to six national quality indicators determined by the Swedish National Board of Health and Welfare was estimated in all patients.Results: We included 3940 patients with the following age distribution: 1.6% were 18-39 years of age, 12.3% 40-59 years, 37.2% 60-74 years, 28.9% 75-84 years and 20% were ≥85 years. Age-dependent differences in implementation rate were present for some of the 13 quality indicators. Compared to elderly cancer patients, younger patients were more likely to be cared for by a specialized palliative care service, more often informed about imminent death as well as assessed for pain. For most national quality indicators, the goal level was not met. Only for the 'on demand prescription for pain', the goal level was reached.Conclusions: EOL care did not meet national quality indicators in this population-based data from Sweden, in particular in the elderly population. Elderly gynaecological cancer patients are at high risk of poorer EOL care without the involvement of specialized palliative care services. Palliative care services need to be implemented across all institutions of EOL care to ensure good and equal care.

Social regulation activities in end-of-life: a qualitative study on completion of advance directives in Swiss nursing homes

Background

In Switzerland as in many countries, steady trend is observed in nursing homes to promote writing of advanced directives (ADs). Implementation of ADs reflects the rise in public concern for the persons’ right to self-determination and informed decision. The issue of end-of-life conditions is particularly acute in situations with dementia. This article investigates how ADs interventions in nursing homes strive simultaneously to behave in line with the principles of care ethics and with the intention to respond to legally binding instructions. Healthcare to dying residents with dementia in nursing homes is interpreted in light of the Regulation theory.

Methods

Nursing home palliative care reference nurses were contacted through questionnaire. One hundred twenty-one addresses were reached, 69 responses were collected, giving a response rate of 57%. In order to deepen the understanding, 10 semi-directive interviews were conducted in 10 different nursing facilities with 12 palliative nurses.

Results

Presently, Swiss nursing homes are lacking a model of AD suitable to people with dementia. The study sheds light on dissimilarities in the purpose assigned to ADs’ procedure in the different facilities. Discrepancies in end-of-life care practices reveal more the influence of structural and organisational devices specific to each setting than conflicting views on end-of-life care principles. We analyse the interpretation of the Law and its implementation in the participating NHs as compromises that could be accounted for as a form of social regulation.

Conclusion

Dementia accentuates the uncertainty inherent to end-of-life trajectories. The implementation of standardised procedures aimed at collecting the wishes of the person deprived of his or her discernment is source of dissonances with regard to the multiple interests involved in these care situations. In this context, the drafting of ADs during end-of-life care in NH correspond to new normative constraints requiring new collective regulation actions.

Impact of the Liverpool Care Pathway on quality end-of- care in residential care homes and home care-Nurses' perceptions

AIM

Aim was to describe how Registered Nurses (RNs) and assistant nurses (ANs) working in residential care homes and home care perceived quality end-of-life care after implementation of the Liverpool Care Pathway (LCP) in terms of subjective importance of care aspects and actual care given.

DESIGN

Descriptive cross-sectional.

METHODS

Registered Nurses (N = 22; 100% response rate) and ANs (N = 120; 59% response rate) working in a Swedish municipality. Data collection with a study-specific questionnaire (50 items) about perceived reality (PR) and subjective importance (SI). Non-parametric statistics.

RESULTS

Implementation of the LCP ensured systematic assessment and alleviation of patients' symptoms and needs. The ANs, more than the RNs, perceived that the patients received the best possible nursing and medical care (p = .01). Both groups considered that communication with patients and families as well as the information exchange between the team members was facilitated. Areas for improvement were identified about psychological and existential support and patients and families' participation in care.

Dementia and Parkinson's Disease: Similar and Divergent Challenges in Providing Palliative Care

Dementia and Parkinson's disease are incurable neurological conditions. Patients often experience specific, complex, and varying needs along their disease trajectory. Current management typically employs a multidisciplinary team approach. Recognition is growing that this team approach should also address palliative care issues to optimize quality of life for patient and family caregivers, but it remains unclear how palliative care is best delivered. To inspire future service development and research, we compare the trajectories and conceptualization of palliative care between dementia and Parkinson's disease. Both Parkinson's disease and dementia are characterized by a protracted course, with progressive but fairly insidious development of disability. However, patients with Parkinson's disease may experience relatively stable periods initially but with time, a wide range of debilitating symptoms develops, many of which do not respond well to treatment. Eventually, dementia develops in most Parkinson patients, while motor disability develops in many dementia patients. In both diseases, symptoms such as pain, apathy, sleeping problems, falls, and a high caregiver burden are prevalent. Advance care planning has benefits in terms of being prepared before the disease progresses into a stage with communication problems or severe cognitive impairment. However, for both conditions, the protracted disease trajectories complicate conceptualization of palliative care through different stages of the disease, with pertinent questions such as when to offer what interventions pro-actively. Given the similarities and differences, we should develop palliative approaches that are partially generic and partially disease-specific. These should be integrated seamlessly with disease-specific care. Substantial research is already being performed on dementia palliative care. This may also inform the further development of palliative care for Parkinson's disease, including an evaluation of palliative interventions and services.