Introducing an integrated care pathway for the last days of life

End-of-life care in hospital: an audit of care against Australian national guidelines

Objective The aim of this study was to map end-of-life care in acute hospital settings against Elements 1-5 of the Australian Commission on Safety and Quality in Health Care's (ACSQHC) Essential Elements for Safe and High-Quality End-of-Life Care. Methods A retrospective medical record audit of deceased in-patients was conducted from 2016 at one public (n = 320) and one private (n = 132) hospital in Melbourne, Australia. Ten variables, key to end-of-life care according to the ACSQHC's Elements 1-5 were used to evaluate end-of-life care. Results Most patients (87.2%) had a limitation of medical treatment. In 91.97% (P < 0.0001) of cases, a written entry indicating poor prognosis preceded a documented decision to provide end-of-life care, with a documented decision noted in 81.1% of cases (P < 0.0001). Evidence of pastoral care involvement was found in 41.6% of cases (P < 0.0001), with only 33.1% of non-palliative care patients referred to specialist palliative care personnel (P = 0.059). An end-of-life care pathway was used in 51.1% of cases (P < 0.0001). Conclusion There is clear scope for improvement in end-of-life care provision. Health services need to mandate and operationalise Elements 1-5 of the ACSQHC's Essential Elements into care systems and processes, and ensure nationally consistent, high-quality end-of-life care. What is known about the topic? Acute care settings provide the majority of end-of-life care. Despite the ACSQHC's Ten Essential Elements, little is known about whether current end-of-life care practices align with recommendations. What does this paper add? There is room for improvement in providing patient-centred care, increasing family involvement and teamwork, describing and enacting goals of care and using triggers to prompt care. Differences between public and private hospitals may be the result of differences in standard practice or policy and differences in cultural diversity. What are the implications for practitioners? The Essential Elements need to be mandated and operationalised into mainstream care systems and processes as a way of ensuring safe and high-quality end-of-life care.

Implementing an integrated pathway to care for the dying: is your organisation ready?

BACKGROUND

Integrated pathways for care of the dying aim to promote the delivery of high-quality palliative care, regardless of access to specialist services.

AIM

To produce a heuristic technique to assist with planning and evaluating the integration of the care of the dying pathway into everyday work.

METHODS

Electronic databases were searched to identify research papers focused on the implementation of integrated pathways for care of the dying in acute hospital settings.

RESULTS

A total of 13 articles were reviewed using the four elements of normalisation process theory-coherence, cognitive participation, collective action and reflexive monitoring. These results informed the development of a heuristic for organisational readiness.

CONCLUSION

The organisational readiness heuristic provides an evidence-based checklist for organisational leaders who are planning to introduce new, or evaluate current, integrated pathways for care of the dying. The next step is to trial the heuristic for feasibility in practice.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study.

AUTHORS' CONCLUSIONS

There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

Negotiating the equivocality of palliative care: a grounded theory of team communicative processes in inpatient medicine

In the majority of U.S. hospitals, inpatient medicine teams make palliative care decisions in the absence of a formalized palliative system. Using a grounded theory approach, interviews with inpatient team members were systematically analyzed to uncover how participants conceptualize palliative care and how they regard the communicative structures that underlie its delivery. During analysis, Weick's model of organizing emerged as a framework that fit the data. The 39 participant inpatient team members discussed palliative care as primarily a communicative process. Themes describing the meaning of palliative care emerged around the concepts of receiver of care, timeline of care, and location of care. The emerging model included four stages in the communicative processes of inpatient palliative care: (a) interpret the need, (b) initiate the conversation, (c) integrate the processes, and (d) identify what works. In contrast to stable, focused palliative care teams or hospice care teams, which have prescribed patient populations and processes, the inpatient medicine team faces the equivocality of providing palliative care within a broader practice. This research offers a four-phase model to show how these inpatient teams communicate within this context. Implications for the provision of palliative care are discussed.

Implementation of improvement strategies in palliative care: an integrative review

Background

The European population is ageing, and as a consequence, an increasing number of patients are in need of palliative care, including those with dementia. Although a growing number of new insights and best practices in palliative care have been published, they are often not implemented in daily practice. The aim of this integrative review is to provide an overview of implementation strategies that have been used to improve the organisation of palliative care.

Methods

Using an integrative literature review, we evaluated publications with strategies to improve the organisation of palliative care. Qualitative analysis of the included studies involved categorisation of the implementation strategies into subgroups, according to the type of implementation strategy.

Results

From the 2379 publications identified, 68 studies with an experimental or quasi-experimental design were included. These studies described improvements using educational strategies (n = 14), process mapping (n = 1), feedback (n = 1), multidisciplinary meetings (n = 1) and multi-faceted implementation strategies (n = 51). Fifty-three studies reported positive outcomes, 11 studies reported mixed effects and four studies showed a limited effect (two educational and two multi-faceted strategies).

Conclusions

This review is one of the first to provide an overview of the available literature in relation to strategies used to improve the organisation of palliative care. Since most studies reported positive results, further research is needed to identify and improve the effects of strategies aiming to improve the organisation of palliative care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0293-2) contains supplementary material, which is available to authorized users.

Evaluating the Liverpool Care Pathway for care of the terminally ill in rural Australia

PURPOSE

This study evaluates a pilot implementation of the Liverpool Care Pathway (LCP), a clinical tool used to guide the care of dying patients in the last days of life, on the end-of-life care for dying patients in three regions in rural Australia.

METHODS

The LCP was implemented at 13 participating sites: nine hospitals (general wards), one community-based palliative care service, and three in-hospital palliative care units. To evaluate the implementation of the LCP, 415 eligible patient records were examined: 223 pre-implementation and 192 post-implementation (116 on the LCP and 76 receiving usual care). The primary analysis compared all patients pre-implementation of the LCP versus all patients post-implementation.

RESULTS

Increases were found post-implementation for communication with other health professionals and with patients or family (pre-69 %, post-87 %; p ≤ 0.000), use of palliative medications (pre-87 %, post-98 %; p ≤ 0.000) and frequency of symptom assessments (pre-66 %, post-82 %; p ≤ 0.000). Fewer blood and radiological investigations were conducted and venous access devices used in the post-implementation groups than in the pre-implementation period.

CONCLUSIONS

This study suggests that when rigorously implemented, the LCP improves important components of end-of-life care for dying patients and their families.

The media critique of the Liverpool Care Pathway: some implications for nursing education

End-of-life care pathways are championed around the globe as tools that might be used to enhance the quality of care at the very end of a person's life. This paper examines recent negative media discourse in the UK about the Liverpool Care Pathway for the Dying Patient (LCP). This media coverage may have had damaging effects, but it has also served to highlight inappropriate and even suboptimal end-of-life care. While recognising the pervading influence of organisational structures and cultures, some implications for initial and ongoing education of nurses are identified.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the results of the searches against the predetermined criteria for inclusion.

MAIN RESULTS

The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update.

AUTHORS' CONCLUSIONS

With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

Overcoming barriers to recruitment in care of the dying research in hospitals

CONTEXT

Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging.

OBJECTIVES

We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives.

METHODS

A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, "Is this patient so unwell that you feel they could die on this admission?" to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died.

RESULTS

In total, 6642 patients were screened. The ward staff answered "yes" to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate.

CONCLUSION

We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

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.

Why is the Liverpool care pathway used for some dying cancer patients and not others? Healthcare professionals' perspectives

Background

Despite evidence suggesting that the Liverpool Care Pathway for the Dying Patient is a structured and proficient means of supporting care delivery in the last hours or days of life, discrepancies in uptake are widespread. This exploratory study sought to understand why patients dying of cancer in oncology wards of one hospital trust were, or were not, supported by the LCP. A purposive qualitative case study design was used; each case represented a patient who had died and their most involved nurse and doctor. In-depth interviews explored both recollections of the ‘case’ and wider experiences of using the Pathway in end-of-life care. Eleven healthcare professionals were interviewed about their involvement in the end-of-life care of six patients. For four of these patients care was supported by the LCP.

Findings

Although doctors and nurses reported they preferred to use the Pathway to ensure comfortable death, an important factor influencing their decisions was time of death. Access to timely senior review was regarded as an essential preliminary to placing patients on the Pathway but delayed access ‘out of hours’ was commonly experienced and tensions arose from balancing conflicting priorities. Consequently, the needs of dying patients sometimes failed to compete with those receiving curative treatment.

Conclusions

This study suggests that greater attention should be focused on ‘out of hours’ care in hospitals to ensure regular senior review of all patients at risk of dying and to support front line staff to communicate effectively and make contingency plans focused on patients’ best interests.

Promoting health and wellbeing at the end of life: the contribution of care pathways

Enhancing end-of-life care (EoLC) is a core component of international governments' health policies. Across the globe, nurses make significant contributions to EoLC and, at this delicate time, have the power to positively influence the health and wellbeing of those facing death. Indeed, health promotion is a core component of the nurse's role. Originating in the UK, EoLC pathways have been adopted around the world. Their broad aim is to optimise the quality of the dying process, enabling people to 'die well' across care settings. This paper examines EoLC pathways in terms of promoting health and wellbeing in this discrete stage of the dying trajectory. Concepts of health and health promotion are described briefly and the idea of health-promoting palliative care and its association with a good death examined. The ensuing discussion relates to two EoLC documents. While acknowledging that much has been achieved it is argued that, despite the potential for promoting health and wellbeing, a professionally led, biomedical approach predominates, and in terms of promoting health and wellbeing at the end of life there is a pressing need for proactive advance care planning at an earlier point in the illness trajectory.

Staff perceptions of end-of-life care following implementation of the liverpool care pathway for the dying patient in the acute care setting: a New Zealand perspective

BACKGROUND AND METHODS

Ensuring appropriate palliative and end-of-life (EOL) care in the acute environment is complex and challenging. The Liverpool Care Pathway (LCP) aims to support staff to provide holistic EOL care utilizing a structured framework to prompt and guide care. We report on the post-implementation findings of a mixed methodology (survey and focus group [FG] forums) study into staff perceptions of EOL care following the pilot implementation of the LCP into two acute wards.

RESULTS AND CONCLUSIONS

Study results suggest that within acute settings staff perceive that the LCP improves EOL care overall, assists interdisciplinary communication around death and dying, and that is a useful tool to positively influence decision making and care delivery. Further research into aspects of staff communication, diagnosing dying, changing direction of care, and the physical environment is warranted.

Understanding integrated care pathways in palliative care using realist evaluation: a mixed methods study protocol

INTRODUCTION

Policy- and evidence-based guidelines have highlighted the need for improved palliative and end-of-life care. However, there is still evidence of individuals dying undignified deaths with little pain control, therefore inflicting unnecessary suffering. New commissioning powers have enabled a 2-year pilot of an innovative integrated care pathway (ICP) designed to improve arrangements for individuals with life-limiting illnesses requiring palliative care. A novel feature of the ICP is its focus on palliative care over the last 6 months of life, aiming to intervene early to prepare for and ensure a good death. What is not known is if this pathway works, how it works and who it works for.

METHODS AND ANALYSIS

A realist evaluation and a complex analytical framework will investigate and discover context, mechanism and outcome conjectures and configurations of the ICP and thus facilitate exploration of how it works and who it works for. A mixed methods approach will be used with small sample sizes to capture the breadth of the ICP. Phase 1 will identify if the pathway works through analysis of NHS Morbidity Information Query and Export Syntax data, locality Death Audit data and the Quality of Dying and Death Questionnaire. Phase 2 employs soft systems methodology with data from focus groups with health professionals to identify how the pathway works. Phase 3 uses the Miller Behavioural Style Scale and interviews with palliative care patients and bereaved relatives to analyse communication in palliative care.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the NHS local ethics committee (REC reference number: 11/NE/0318). Research & Development approval has been gained from four different trusts, and relevant voluntary organisations and the local council have been informed about the research. This protocol illustrates the complexity inherent in evaluating a palliative care ICP. Identification of whether the pathway works, how it works and who it works for will be beneficial to all practices and other care providers involved as it will give objective data on the impact of the ICP. Results will be disseminated throughout the study for continuous quality improvement of the ICP. Outcomes from each data collection phase will be disseminated separately if analysis warrants it; all data collection will be utilised in the realist evaluation. The research provides a potential for the dissemination of the pathway to other localities through the transferable knowledge it will generate, from its focus on the contexts that are crucial for successful implementation, the mechanisms that facilitate implementation and the outcomes achieved.

Initiating end-of-life care pathways: a discussion paper

AIMS

To discuss the intricacies of the decision-making process about initiating end-of-life care pathways.

BACKGROUND

Internationally, enhancing the quality of end-of-life care has become a central concern in governments' health policies. Despite limited empirical evaluation, end-of- life care pathways have been championed and widely adopted as complex interventions to enhance end-of-life care worldwide.

DATA SOURCES

A literature search of established electronic databases was conducted for published articles in English addressing decision-making and end-of-life care pathways between 1997-2010. Manual searches of relevant journals and internet sites were also undertaken.

DISCUSSION

The initiation of an end-of-life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision-making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end-of- life care. Accordingly, nurses need not only an appreciation of end-of-life care pathways, but the complexities surrounding the decision to commence a pathway and their role within.

CONCLUSION

The initiation of an end-of-life care pathway is contingent on the outcome of a complex decision-making process which is rarely explored and poorly understood.

End-of-life care pathways as tools to promote and support a good death: a critical commentary

This paper calls into question whether and how end-of-life care pathways facilitate the accomplishment of a 'good death'. Achieving a 'good death' is a prominent social and political priority and an ideal which underpins the philosophy of hospice and palliative care. End-of-life care pathways have been devised to enhance the care of imminently dying patients and their families across care settings and thereby facilitate the accomplishment of a 'good death'. These pathways have been enthusiastically adopted and are now recommended by governments in the UK as 'best practice' templates for end-of-life care. However, the literature reveals that the 'good death' is a nebulous, fluid concept. Moreover, concerns have been articulated regarding the efficacy of care pathways in terms of their impact on patient care and close analysis of two prominent end-of-life pathways reveals how biomedical aspects of care are privileged. Nonetheless drawing on a diverse range of evidence the literature indicates that end-of-life care pathways may facilitate a certain type of 'good death' and one which is associated with the dying process and framed within biomedicine.

Nurses' views on using the Liverpool care pathway in an acute hospital setting

The Liverpool Care Pathway (LCP) is one of three major recent UK initiatives to improve the care of people dying with malignant and non-malignant disease. This focus group research aimed to explore nurses' perceptions of using the LCP in an acute hospital setting, their perceptions of its impact on patient care, and their confidence in care at the end of life, as well as to generate new ideas among peers. Six themes were identified: use of the LCP as a care tool; improved confidence, training, and support; the nursing-medical relationship; dying in hospital; and end-of-life issues. The nurses reported that the LCP has increased their confidence and resulted in improved patient care. Exploring the effect of the LCP on patient care may provide valuable data that may inform how the LCP is integrated into practice in the future.

End-of-life care pathways in acute and hospice care: an integrative review

CONTEXT

Over the past decade, there has been widespread adoption of end-of-life care pathways as a tool to better manage care of the dying in a variety of care settings. The adoption of various end-of-life care pathways has occurred despite lack of robust evidence for their use.

OBJECTIVES

This integrative review identified published studies evaluating the impact of an end-of-life care pathway in the acute and hospice care setting from January 1996 to April 2010.

METHODS

A search of the electronic databases Scopus and Cumulative Index of Nursing and Allied Health Literature as well as Medline and the World Wide Web were undertaken. This search used Medical Subject Headings key words including "end-of-life care," "dying," "palliative care," "pathways," "acute care," and "evaluation." Articles were reviewed by two authors using a critical appraisal tool.

RESULTS

The search revealed 638 articles. Of these, 26 articles met the inclusion criteria for this integrative review. No randomized controlled trials were reported. The majority of these articles reported baseline and post implementation pathway chart audit data, whereas a smaller number were local, national, or international benchmarking studies. Most of the studies emerged from the United Kingdom, with a smaller number from the United States, The Netherlands, and Australia.

CONCLUSION

Existing data demonstrate the utility of the end-of-life pathway in improving care of the dying. The absence of randomized controlled trial data, however, precludes definitive recommendations and underscores the importance of ongoing research.

Staff perceptions of end-of-life care in aged residential care: a New Zealand perspective

BACKGROUND

Increasingly, aged residential care (ARC) facilities are places where the lives of older people with complex care needs end. Hence, end-of-life (EOL) care is a significant component of work for ARC staff. In the absence of New Zealand research, staff perceptions of EOL care were sought at three aged-care facilities in a New Zealand District Health Board region. The research provided valuable data regarding care delivery and can be used to inform the introduction of an integrated care pathway (ICP). EOL care pathways are not commonly used in New Zealand ARC facilities and the influence of ICPs, such as the Liverpool Care Pathway (LCP) for the dying patient has not been investigated. Additionally, most international studies report on the introduction of the LCP without baseline preimplementation data.

DESIGN

In the present study, staff (n = 195) involved in caring for residents, their families, and whānau at EOL were surveyed to obtain demographic data and staff perceptions of EOL care via Likert scale and open ended questions.

RESULTS

A response rate of 32% was obtained. Respondents indicated a relatively high level of confidence regarding their care of the dying, including aspects of communication, teamwork and use of documentation. However, this was often contradicted by their written responses. Written comments were analyzed thematically and six themes identified: the naturalness of dying; the character of care; care relationships; emotional response; knowledge; and the organizational environment. Data analysis provided a rich and informative description of staff perceptions of EOL and issues influencing care.

Experiences of hospital care reported by bereaved relatives of patients after a stroke: a retrospective survey using the VOICES questionnaire

AIM

This paper is a report of a study conducted to explore the determinants of satisfaction with health and social care services in the last 3 months and 3 days of life as reported by bereaved relatives of those who died from a stroke in an institutional setting.

BACKGROUND

There is limited research about how best to meet the needs of those who die from stroke. A thorough understanding of the determinants of satisfaction with end of life care is crucial for effective service provision to increase awareness of the needs of dying patients.

METHODS

During a six-month period in 2003, a population-based survey of bereaved relatives of patients after stroke was conducted using a stroke-specific version of the Views of Informal Carers Evaluation of Services postal questionnaire (183 informants, response rate 37%). The sub-sample included those informants who reported that the deceased person had died in an institutional setting (91%, n = 165). The analysis was divided into two phases: univariate (Pearson chi-square test) and multivariate phase (logistic regression).

RESULTS

Logistic regressions showed that discussing any worries about the treatment of the deceased person and feeling that the doctors and nurses knew enough about their condition were predictors of satisfaction with doctors and nurses in the last 3 months of life. Meeting the personal care needs of the deceased person, being involved in decisions and feeling that the deceased person died in the right place were predictors of satisfaction with care in the last 3 days of life.

CONCLUSION

End of life care needs to address the individual needs of patients who die from stroke and those close to them. This study shows that individualised end of life care increases satisfaction and, although the data reported in this paper reflect care in 2003, there is no more recent evidence that contradicts this important overall finding.

The Liverpool Care Pathway in intensive care: an exploratory study of doctor and nurse perceptions

The Liverpool Care Pathway (LCP) provides an evidence-based framework of care for the dying patient and provides guidance on comfort measures, discontinuation of inappropriate interventions, anticipatory prescribing, holistic care and care of the family after death. End-of-life care is becoming an important issue in critical care, and the LCP has been adapted for use in intensive care units in the United Kingdom. A qualitative study using descriptive phenomenology was used to explore doctor and nurse experiences of the impact of the LCP in two intensive care units in a 1000-bed teaching hospital in the north-west Midlands. The staff experience of the LCP was dependent on their role, with mixed reports about frequency of use and level of education received on the LCP. Education and adequate support was identified as being pivotal to the successful implementation of any type of LCP.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).

SEARCH STRATEGY

The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors.

MAIN RESULTS

The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review.

AUTHORS' CONCLUSIONS

Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.

Diagnosing dying in the acute hospital setting--are we too late?

Studies have shown that end-of-life care within the UK hospital setting is variable, and care pathways are now being advocated in the UK. This report presents results from an audit revealing that it is possible to anticipate a large proportion of deaths within an acute setting, but this is generally achieved very close to the end of life. Forty-nine per cent of patients were recognised as dying 24 hours or less before death, 17% between 24 and 36 hours before death, 21% between 36 and 72 hours before death, and 13% greater than 72 hours before death. It discusses the challenges around making the 'diagnosis of dying' and highlights that if clinicians do not feel confident in performing such a diagnosis, then patients cannot benefit from end-of-life care pathways. Instead of asking healthcare professionals to make accurate prognoses or diagnose dying, an environment needs to be created where teams feel comfortable in actively managing patients (appropriately) alongside considering their symptom control and planning for possible end-of-life care.

End-of-life care pathways

PURPOSE OF REVIEW

To summarize recent research findings about the use and effects of integrated care pathways for end-of-life care.

RECENT FINDINGS

Integrated care pathways designed for patients at the end of life include the Liverpool Care Pathway, used widely in the UK, and Palliative Care for Advanced Disease, developed in the USA. There is general consensus in the current literature that integrated care pathways improve standardization, continuity and collaboration among the interdisciplinary team. Although recent studies on integrated care pathways for dying patients have been predominantly descriptive, previous studies demonstrate improved symptom assessment, documentation of care goals, compliance with standardized guidelines and pain control.

SUMMARY

The use of integrated care pathways for dying patients has the potential to improve care by promoting best practice and standardizing care. In addition, these pathways may improve documentation and provide a mechanism for measuring patient outcomes. Although recent studies on the use of these integrated care pathways are descriptive, some publications have demonstrated improved patient outcomes and processes of care. As their use expands, more studies on the effects and outcomes of these care pathways are anticipated.

The effect of the Liverpool Care Pathway for the dying: a multi-centre study

We studied the effect of the Liverpool Care Pathway (LCP) on the documentation of care, symptom burden and communication in three health care settings. Between November 2003 and February 2005 (baseline period), the care was provided as usual. Between February 2005 and February 2006 (intervention period), the LCP was used for all patients for whom the dying phase had started. After death of the patient, a nurse and a relative filled in a questionnaire. In the baseline period, 219 nurses and 130 relatives filled in a questionnaire for 220 deceased patients. In the intervention period, 253 nurses and 139 relatives filled in a questionnaire for 255 deceased patients. The LCP was used for 197 of them. In the intervention period, the documentation of care was significantly more comprehensive compared with the baseline period, whereas the average total symptom burden was significantly lower in the intervention period. LCP use contributes to the quality of documentation and symptom control.

Process mapping: enhancing the implementation of the Liverpool Care Pathway

Arohanui Hospice is a 12-bed specialist palliative care service based in Palmerston North, New Zealand. It serves a population of 180 000 people spread over a wide geographical area, both urban and rural. The Liverpool Care Pathway (LCP) was initially implemented at the hospice inpatient unit in January 2005. Following this, the 'LCP Pilot Project' was developed. This project involved the implementation of the LCP within three aged residential care facilities and two wards within the regional hospital. Included in the project was a research component to enable evaluation of the effectiveness of the LCP in each setting. This article will consider and demonstrate the use of process mapping (Buckman, 2003) as a quality improvement tool to enhance the effective implementation and sustained use of the LCP for the dying patient within aged residential care. Measures are considered that support the implementation of the LCP at an organisational level rather than at a purely clinical level. While this work has been completed within the New Zealand context, it is believed that the principles are transferable to similar settings internationally.

The evaluation of an end-of-life integrated care pathway

AIM

this evaluation set out to examine the needs of staff as they adopted an end-of-life integrated Care Pathway (ICP), and its impact on both service users and providers.

METHOD

semi-structured interviews were conducted with palliative care specialists, other health care professionals and bereaved carers.

RESULTS

the challenges encountered revolved around the multitude of settings, and professionals involved; around the diagnosing of dying; communication with patients and the provision of emotional or spiritual support. Ongoing challenges at the end of the evaluation were those of addressing spirituality and some of the established practices. However, there was general consensus that the ICP facilitated greater consistency of care, improved continuity, and ensured a proactive rather than a reactive approach to care. All these were recognised and appreciated by bereaved carers.

CONCLUSION

end of life is now every health care professional's business and this may have the potential to raise the place of palliative care in general on the professional agenda.

Barriers to implementing an integrated care pathway for the last days of life in nursing homes

AIM

this paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes.

METHODS

an action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway.

FINDINGS

six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional 'rehabilitative' culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathway for the last days of life less straightforward than in other settings.

CONCLUSION

it cannot be presumed that the implementation of a care pathway for the last days of life in nursing homes is straightforward. This study suggests that an action research framework was extremely useful in highlighting and overcoming some obstacles when developing evidence-based practice. Action at both local and public policy level is required to fully address barriers that prevent quality end-of-life care in nursing homes.

Bridging the specialist-generalist divide: a creative Master's programme initiative

This article outlines the development of a new Master's programme that is suitable particularly for those who are interested in managing palliative care in generalist care contexts. Disseminating the essence of excellent palliative care provision, accessible by the minority to the majority in need, has been an issue for some time. National Service Frameworks identify the contribution of both education and workforce planning to facilitate such provision. A gradual shift in design of palliative programme provision has seen the emergence of education that is more malleable to varied practice contexts. This new MSc Palliative Care Programme is centred on interprofessional education, and through collaborative working, shares modules with a neighbouring university to produce financially viable provision. Essential palliative content is delivered in compulsory taught modules, however, elective options include open or work-based modules that facilitate palliative practice development tailored to specific context need. Postgraduate study, associated with leading practice, means that a few key staff can significantly impact disseminating enhanced palliative practice across care environments. In this way, in the community and in institutions where the majority of older people dying of chronic illness are cared for, resources can be used purposefully to maximize the chance of 'a good enough death' (McNamara, 2001).