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End-of-Life Care Pathways in Acute and Hospice Care: An Integrative Review

Open AccessPublished:March 14, 2011DOI:https://doi.org/10.1016/j.jpainsymman.2010.07.020

      Abstract

      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.

      Key Words

      Introduction

      The setting and manner in which people die is of interest to clinicians and policy makers as a way not only of meeting consumer choice, in relation to dying with dignity, but also of reducing costs and avoiding unnecessary and clinically futile interventions. Most deaths in the developed world now occur in the acute care setting,
      • Flory J.
      • Yinong Y.X.
      • Gurol I.
      • et al.
      Place of death: U.S. trends since 1980: fewer Americans died in the hospital in 1998 than in 1980, but some racial disparities raise troubling questions.
      • Gomes B.
      • Higginson I.J.
      Where people die (1974-2030): past trends, future projections and implications for care.
      and this is expected to increase as the population ages and more people die of chronic and complex conditions.
      • Kaldjian L.C.
      • Curtis A.E.
      • Shinkunas L.A.
      • Cannon K.T.
      Goals of care toward the end of life: a structured literature review.
      Yet, few of these acute care deaths will be managed by specialist palliative care providers, with most being handled by health professionals with no formal training in diagnosing dying and for whom end-of-life care is not their primary area of expertise.
      • Gibbins J.
      • McCoubrie R.
      • Alexander N.
      • Kinzel C.
      • Forbes K.
      Diagnosing dying in the acute hospital setting—are we too late?.
      In the acute care environment, where the focus has traditionally been on “curing and prolonging life,” there can be tensions and challenges in moving care toward a symptom management model, such as palliative care.
      • Gibbins J.
      • McCoubrie R.
      • Alexander N.
      • Kinzel C.
      • Forbes K.
      Diagnosing dying in the acute hospital setting—are we too late?.
      Supporting patients and families to make this transition in a curative culture can seem confronting to many acute care health professionals and, in part, may explain late recognition of dying and a delay in initiating end-of-life care in hospitals. Unfortunately, late recognition of dying is likely to result in poor symptom management and suboptimal psychosocial and spiritual care for dying patients and their families.
      • Al-Qurainy R.
      • Collis E.
      • Feuer D.
      Dying in an acute hospital setting: the challenges and solutions.
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      Consumer concerns over inadequate end-of-life care have been identified in various international health service reform agendas
      • National Health and Hospitals Reform Commission
      A healthier future for all Australians.
      and currently accounts for more than half of all complaints received by the National Health Service.
      • Al-Qurainy R.
      • Collis E.
      • Feuer D.
      Dying in an acute hospital setting: the challenges and solutions.
      The seminal work of Ellershaw and colleagues in developing integrated end-of-life care pathways emerged in response to the shortcomings of the health care system’s capacity to deliver evidence-based end-of-life care in the late 1990s.
      • Ellershaw J.
      Care of the dying: what a difference an LCP makes!.
      • Ellershaw J.
      • Foster A.
      • Murphy D.
      • Shea T.
      • Overill S.
      Developing an integrated care pathway for the dying patient.
      • Ellershaw J.
      • Ward C.
      Care of the dying patient: the last hours or days of life.
      Integrated care pathways detail the essential elements of care required to manage a specific clinical problem and ensure that the best available evidence is systematically integrated into care delivery while providing a framework for auditing and benchmarking care.
      • Campbell H.
      • Hotchkiss R.
      • Bradshaw N.
      • Porteous M.
      Integrated care pathways.
      The Liverpool Care Pathway (LCP) was designed to improve care of cancer patients in the last 48 hours of life and facilitate monitoring of the level and type of end-of-life care provided.
      • Ellershaw J.
      • Ward C.
      Care of the dying patient: the last hours or days of life.
      A multidisciplinary team philosophy underpins the approach of this end-of-life care pathway, which is divided into three sections: initial assessment, ongoing care, and care after death, with 18 goals of care identified.
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      The template provides an aid to decision making, with the pathway replacing all other documentation.
      • Ellershaw J.
      • Ward C.
      Care of the dying patient: the last hours or days of life.
      Over the past decade, the LCP has undergone many revisions and is now used in more than 1000 care organizations in the United Kingdom.
      • Ellershaw J.
      Care of the dying: what a difference an LCP makes!.
      • Ellershaw J.
      • Gambles M.
      • McGlinchey T.
      Benchmarking: a useful tool for informing and improving care of the dying?.
      The LCP is a key element of the Gold Standards Framework promoted by the National Institutes of Clinical Excellences in the United Kingdom to facilitate the delivery of palliative care beyond specialist care settings.
      • Shaw K.
      • Clifford C.
      • Thomas K.
      • Meehan H.
      Improving end-of-life care: a critical review of the gold standards framework in primary care.
      More recently, the pathway has been adapted for use in other population groups, such as people dying with advanced chronic kidney disease
      • Douglas C.
      • Murtagh F.E.M.
      • Chambers E.J.
      • Howse M.
      • Ellershaw J.
      Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group.
      or from stroke and those dying in the emergency setting; these adaptations have been accomplished in parallel with translation of the LCP into other languages.
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      • Swart S.
      • van Veluw H.
      • van Zuylen L.
      • Gambles M.
      • Ellershaw J.
      Dutch experiences with the Liverpool Care Pathway.
      The widespread diffusion of the end-of-life pathway has resulted in the development and implementation of end-of-life care pathways in the United States,
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      Europe,
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      Australia,
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      and China.
      • Lo R.S.K.
      • Woo J.
      Palliative care in old age.
      These pathways are now used in hospices, acute care, community, and residential aged care sectors.
      • Ellershaw J.
      Care of the dying: what a difference an LCP makes!.
      • Luhrs C.A.
      • Penrod J.D.
      End-of-life care pathways.
      Despite the end-of-life care pathways’ widespread adoption, recent public comments have called into question the promotion and adoption of these clinical tools because of fears that these pathways fail to be sensitive enough to accurately diagnose dying or meet the individual needs of dying people; there is concern that they may actually hasten death, particularly if all reversible causes for decline are not systematically investigated.
      • Shah S.H.
      The Liverpool Care Pathway: its impact on improving the care of the dying.
      • Treloar A.J.
      Continuous deep sedation: Dutch research reflects problems with the Liverpool care pathway.
      A recent Cochrane review found 920 potentially relevant articles but no studies that met the inclusion criteria of a randomized controlled trial, confirming widespread uptake of the pathway in the absence of supporting evidence.
      • Chan R.
      • Webster J.
      End-of-life care pathways for improving outcomes in caring for the dying.
      This review concluded that there was no evidence of harm that would prevent the use of the end-of-life pathway to manage the care of people actively dying.
      • Chan R.
      • Webster J.
      End-of-life care pathways for improving outcomes in caring for the dying.
      In an era of evidence-based medicine, parallels can be drawn between the rapid uptake of the end-of-life care pathway and laparoscopic cholestectomy,
      • Hunter J.G.
      Clinical trials and the development of laparoscopic surgery.
      with both practices being adopted in a vacuum of evidence from randomized controlled trials.
      Given the global adoption of the end-of-life care pathway, emerging concerns over its use, and a lack of randomized controlled trials,
      • Chan R.
      • Webster J.
      End-of-life care pathways for improving outcomes in caring for the dying.
      there is a need for further appraisal of the end-of-life care pathway.
      • Shah S.H.
      The Liverpool Care Pathway: its impact on improving the care of the dying.
      The purpose of this integrative review was to identify published studies describing the use of the end-of-life care pathway to determine its 1) impact on consumers (patients and families), health professionals, and the acute care and/or hospice systems and 2) barriers and facilitators to its implementation. The integrative review aimed to address the following questions: 1) In which population(s) has the end-of-life care pathway predominately been used to manage care of the dying? 2) Is there evidence to support the end-of-life care pathway’s use in acute care and/or hospice systems? 3) What are the implications of these findings for evidence-based care of the dying in the acute care and/or hospice setting? 4) What are the key elements underpinning effective implementation of the end-of-life care pathway? and 5) What are the gaps in the evidence and future research directions?

      Methods

      Definitions

      An integrative review, using prespecified parameters, allows systematic appraisal of the literature and synthesizing of research findings on a focused topic. This method allows for the inclusion of varied research designs and methodological approaches to provide a comprehensive analysis of a topic and draw overall conclusions from primary studies.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      An integrative review includes problem identification, a literature search, data evaluation, data analysis, and presentation.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      This structured and focused approach to conducting a literature review is appropriate in subject areas where a summation of effect and identifying issues of implementation are beneficial. Similar approaches to a systematic review are incorporated in this technique to ensure rigor through a standardized review protocol to enable replication.
      • Ganong L.H.
      Integrative reviews of nursing research.

      Setting and Sample

      Both randomized and nonrandomized studies were eligible for inclusion in this review. Articles were selected if an end-of-life care pathway was used to manage the dying phase in the acute care and/or hospice setting and if care delivered to dying patients and/or their families was evaluated. Articles were excluded if they reported a single case study or described process measures only.
      This integrative review was conducted over the period from November 1, 2009 to the final week of April 2010. The initial literature search was undertaken in Cumulative Index of Nursing and Allied Health Literature, Medline, Embase, PsycINFO, Scopus, and the World Wide Web, using Google Scholar and Mednar search engines, and was limited to articles published since 1996 in the English language, related to adult patients. The Medical Subject Headings (MeSH) terms were identified, with four key concepts explored: acute care, palliative care, end-of-life care, and pathways. MeSH key words including palliative care, terminal care, end-of-life care, dying, acute care, pathways, integrated care pathway, end-of-life care pathway, evaluation, and health services research were used in the search. Reference lists were checked for additional sources; hand searching of relevant journals also was undertaken.
      The search strategy generated 638 articles. No randomized controlled trials or meta-analyses were identified. Five hundred sixty articles were excluded based on the inclusion criteria, leaving 78 potential studies to be included in the review. After reviewing the full article, 52 of these articles were rejected because they did not provide empirical data about the impact of the end-of-life care pathway for adults dying in the acute care or hospice setting. Articles that were rejected tended to describe single case studies, or the development or implementation process, without reporting outcomes. Three studies did not meet the inclusion criteria because these were not available in English, and a further four articles were rejected because they were editorials. At the end of this process, 26 studies matched the inclusion criteria.

      Data Analysis

      Appraising the quality of a study for inclusion in an integrative review is a complex undertaking.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      To assist with this quality assessment process, two evidence evaluation tools developed by the Australian Palliative Residential Aged Care (APRAC) Project Guidelines were used to appraise the studies.
      • Australian Department of Health and Ageing and National Health and Medical Research Council
      Guidelines for a palliative approach in residential aged care—Enhanced version.
      The APRAC quantitative studies evaluation tool adopted the Australian National Health and Medical Research Councils level of evidence categories.

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      This tool was modified to include verifiable quality or program evaluation data (Level V evidence).
      • Stetler C.B.
      • Morsi D.
      • Rucki S.
      • et al.
      Utilization-focused integrative reviews in nursing service.
      This data extraction tool facilitated a systematic approach to appraising the strength of the evidence, and the quality of methods used, while determining the transferability of the results to make a recommendation about the pathway’s applicability.
      • National Health and Medical Research Council
      NHMRC additional levels of evidence and grades for recommendations for developers of guidelines: Stage 2 consultation.
      The APRAC qualitative studies level of evidence (Level QE) evaluation tool uses eight questions to appraise the aim of the study and appropriateness of the method.
      • Australian Department of Health and Ageing and National Health and Medical Research Council
      Guidelines for a palliative approach in residential aged care—Enhanced version.
      For each included study, data on methods, setting, population, findings, evidence levels, implementation features, and strengths and weaknesses of the approach were extracted onto the data collection tool and into a matrix by J. L. P. and P. M. D. In the event of disagreement, a third reviewer (E. J. H.) provided clarification. This process facilitated the summary of key points and synthesizing of information to inform organizational decision making around the implementation of an end-of-life care pathway. After completion of the matrix, it became clear that the heterogeneity of studies precluded formal meta-analysis. Therefore, thematic content analysis was undertaken to identify key issues.

      Results

      Table 1 summarizes the 26 studies included in this integrative review and data elements included in the data analysis process. The defining features of each study are summarized in Table 2. In accordance with the hierarchy of evidence,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      most studies (n=11) were case series reporting pre- and post-test outcomes (Level IV), with the highest level of evidence (Level III-3) coming from a small number (n=2) of comparative studies without concurrent controls. Despite this limitation, the studies included in this review provided useful insights into the level of end-of-life care delivered and information relating to the pathway implementation process.
      Table 1Summary of Included Studies
      SourceCountryFocusDesignParticipantsOutcomesLevel of EvidenceFeatures
      van der Heide et al. 2010
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      The NetherlandsUse of LCP for management of cancer deaths in acute, aged, and a home care setting.Mixed method. Survey and retrospective baseline and prospective post-LCP chart audit. No control.
      • Survey: Physicians and families of 311 deceased cancer patients:
      • Chart audit (n=231) prospective post-test recruitment.
      Pathway usage had no significant impact on the types of drugs used in the last 72 hours of life and reduced the use of drugs with a potentially life-shortening effect from 46% to 28%.IV
      • Physician survey
      • Carer survey
      • Chart audit
      • Prospective recruitment
      Jackson et al. 2009
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      AustraliaUse of modified LCP in four general medical wards.Retrospective baseline (limited data) and post-LCP chart audit. No control.Baseline audit (n=15) and post-pathway audit (n=20).Descriptive statistics only. Limited baseline data reported. Increased adherence to evidence-based care observed in 20 KPIs.V
      • QI Project
      • Two-month pilot facilitator 4/12
      • Multidisciplinary education
      • 20 KPIs
      Mullick et al. 2009
      • Mullick A.
      • Beynon T.
      • Colvin M.
      • et al.
      Liverpool Care Pathway carers survey.
      United KingdomPerception of carers of people who had died on LCP in acute care.Prospective carer survey based on the LCP domains of care. No control.Survey offered to 42 consecutive carers over a 14-week period.Small sample (n=25) precludes statistical analysis. 59% response rate. 84% reported high levels of satisfaction.VCarer survey
      Paterson et al. 2009
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      United KingdomUse of modified LCP in a short-stay emergency ward.Mixed method. Retrospective post-LCP chart audit. No control. Health care provider survey.
      • Post-LCP audit (n=61).
      • Open question web survey (n=17).
      Descriptive statistics only. Survey themes: improved continuity of care, documentation of care, and communication—team and patient/family.V
      • Senior Clinical Leadership
      • Medical facilitator
      • Changes to LCP: IV instead of SC meds and hourly observations instead of four hourly
      Lo et al. 2009
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      ChinaUse of modified LCP for people dying from cancer in an inpatient palliative care unit.Retrospective benchmarking LCP chart audit—three sites: Rotterdam, United Kingdom, and China. Unmatched sample. No control.Post-LCP audit China (n=51); compared with United Kingdom (n=40) and Rotterdam (n=40).Descriptive statistics only. 25% missing data—awareness of dying and religious or spiritual needs.IV
      • Modified LCP: focused on seven of the 18 domains.
      • Symptom assessments done eight hourly instead of four hourly because of workforce issues
      The Marie Curie Palliative Care Institute, 2009
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      United KingdomImpact of LCP on EOL care in acute hospitals.Retrospective LCP chart audit. Repeat 2007 methodology.
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      No control.
      Invitation sent to 214 hospitals in 140 acute care trusts. Audit of 30 (max) consecutive deaths on LCP in each participating hospital from October 2008–December 2008. 155 hospitals from 114 acute hospital trusts (n=3893 patients) participated.68% of sites using LCP. 21% of all patients who died were on LCP. 39% of sites had an LCP facilitator and 99% of sites have an SPC team. 61% of people on LCP had a diagnosis other than cancer. 33 hours median time on LCP. Drugs prescribed for agitation and restlessness were only given in 37% of cases.IV
      • Audit tool
      • Centralized audit process
      Veerbeek et al. 2008
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      The NetherlandsImpact of LCP on communication and carers' bereavement.Retrospective pre-post test design questionnaire administered three months after death. No control.
      • Pretest (n=131) and post-test (n=140).
      • 59% eligible relatives.
      Similar patient and relative characteristics at both times. Evidence that the LCP moderately contributes to lower levels of bereavement in relatives.IVPathway used across multiple settings
      Veerbeek et al. 2008
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      The NetherlandsImpact of LCP on symptom burden and communication in seven settings: four oncology units, two aged care facilities, and one home care organization.Mixed methods. Prospective pretest (2003–05) and post-test (2005–06) chart audit. No control. Surveys: nurse and carer.
      • Pretest: chart audit (n=220), nurse survey (n=219), and carer survey (n=130).
      • Post-test: chart audit (n=255); Survey: nurses (n=253) and carers (n=139).
      No statistical difference in patient characteristics. Improvement in aspects of care documented with LCP (P<0.001). Perception that symptom burden is less on LCP: nurse (P=0.008) and relatives (P=0.016). Nurses’ assessments not blinded.IV
      • Patient consent
      • RN—data collection role
      Hardy et al. 2007
      • Hardy J.R.
      • Haberecht J.
      • Maresco-Pennisi D.
      • Yates P.
      Audit of the care of the dying in a network of hospitals and institutions in Queensland.
      AustraliaLCP audit tool used to identify EOL priority areas in three hospices, four hospitals, and one aged care facility in a defined geographical area.Retrospective baseline LCP chart audit. No control.Eight health care institutions completed the baseline audit on 20 consecutive charts (n=160).Descriptive statistics only. Discussion focuses on differences between settings but data not provided.V
      • Linked to LCP audit team
      • Audit undertaken by participating organization
      The Marie Curie Palliative Care Institute, 2007
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      United KingdomImpact of LCP on EOL care in U.K. acute care sector.Retrospective LCP chart audit—30 (max) consecutive deaths on LCP in each participating hospital from September 2006–November 2006.Invitation sent to 209 hospitals in 108 acute care trusts. 94 hospital trusts (n = 2672 patients) participated.Descriptive statistics only. 40% of all hospitals and 60% of acute care trusts participated. Variations across setting. 15% of patients on LCP at time of death. Median time on LCP 33 hours. 55% of patients had a non-cancer diagnosis. 47% of sites had an LCP facilitator. SPC team present at 95% of sites.IV
      • Audit tool
      • Centralized audit process
      Lhussier et al. 2007
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      United KingdomPerception of health professionals and bereaved carers familiar with the LCP in two primary care trusts.Qualitative study. Semistructured interviews.Pathway facilitators (n=22), nurses (n=10), and bereaved carers (n=10).Multiple challenges identified related to variability across care settings, communication with patients, and the provision of emotional or spiritual support. Perception that ICP promoted greater care consistency, improved continuity, and facilitated proactive care delivery.QE
      • ICP facilitator:
      • Site A–bought in specialist time to lead the implementation
      • Site B—generalist time was bought out to lead the implementation
      Hugel et al. 2006
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      United KingdomManagement of RTS in people dying on the LCP in a specialist palliative care unit.Retrospective pretest and prospective post-test chart audit. No control.Matched sample. Prospective data—RTS patients on glycopyrronium (n=36) compared with those on hyoscine (n=36) (retrospective data).Glycopyrronium group more likely to have a response than the hyoscine group (P<0.01). No statistical difference in the levels of agitation observed in the glycopyrronium and hyoscine groups.IVEvaluation symptom management
      Veerbeek et al. 2006
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      The NetherlandsComparison of EOL care in an inpatient palliative care unit in The Netherlands and a hospice in the United Kingdom.Retrospective benchmarking LCP audit comparing two sites. No control.
      • 40 deceased records each site (n=80).
      • Matched sample by age and gender.
      Descriptive statistics only. 9/14 goals of care achieved for >80% of deceased at both sites.IV
      • LCP audit tool
      • Benchmarking
      Gambles et al. 2006
      • Gambles M.
      • Stirzaker S.
      • Jack B.A.
      • Ellershaw J.E.
      The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions.
      United KingdomLCP perceptions of hospice clinicians.Qualitative study. Semistructured interviews.
      • Nurses (n=8).
      • Doctors (n=3).
      Perception that the LCP has a role in the hospice setting; improves documentation, promotes continuity of care, and enhances communication and care of relatives.QEOngoing LCP education and feedback
      Hinton and Fish, 2006
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      IrelandUse of a modified LCP for people dying in an acute renal ward.Retrospective baseline and post-LCP chart audit. No control.Baseline sample (n=10) and post-LCP (n=10).Small sample precludes statistical analysis.V
      • Modified LCP
      • Education program
      • Clinical champion two days/week
      • Link nurse
      • Audit
      Main et al. 2006
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      United KingdomUse of an SCP for older people dying in acute care.Retrospective baseline and post-SCP chart audit. No control.Baseline sample (n=34) and post-SCP sample (n=35).Preliminary data Improvements in all SCP domains. Formal evaluation to be undertaken.V
      • Development SCP
      • Project Team
      Bailey et al. 2005
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      United StatesUse of inpatient comfort care order sets for people dying in acute care.Retrospective baseline and postcomfort care order sets audit of last seven days of care. No control.Baseline sample (n=108) and postcomfort care order set plan sample (n=95).Intervention improved EOL care with an increase in the mean number of symptoms documented, comfort care order sets implemented, and opioid and DNR orders (P<0.001).IV
      • Physician lead
      • Veterans
      • Clinician education
      • Case identification—pocket card
      • Comfort care order set with capacity for active treatments to be maintained
      Luhrs et al. 2005
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      United StatesUse of PCAD pathway for people dying of cancer in acute oncology ward.Controlled retrospective baseline and post-PCAD chart audit. Noncomparable sampling.
      • Pre-PCAD cancer deaths (n=10); consecutive medical ward deaths (non-PCAD or control group) during the implementation period (n=14); and
      • post-PCAD consecutive oncology unit cancer deaths (n=15) managed on PCAD pathway.
      No significant characteristic difference between patient groups. Evidence that introduction of PCAD improved EOL care with better goals of care documentation (P = 0.0001), fewer interventions and more symptoms assessed (P = 0.004) and symptoms managed in accordance to guidelines (P = 0.02).III–3
      • QI team
      • Audit tool
      • Discipline-specific templates
      • Education
      • Role clarification
      • Evaluation-feedback tools
      Bookbinder et al. 2005
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      United StatesImpact of PCAD pathway on patient’s access to resources, communication, and care delivery in a geriatric or oncology unit (study units), palliative care unit (benchmark), or two general medical units (comparison).Retrospective baseline and post-PCAD chart audit.
      • Pretest (n=101).
      • Posttest (n=156).
      33% of patients on the geriatric/oncology units and 100% on the palliative care unit died on the PCAD. Despite positive results, unable to confirm if the PCAD drove improvements in the care of the dying.III–3
      • Quality improvement
      • Multidisciplinary task force
      • Education program
      • Implementation strategy—“clinical champion”
      • Evaluation tools and feedback
      Mirando et al. 2005
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      United KingdomImpact of LCP in 18 clinical areas in six acute hospitals.Retrospective baseline and post-LCP chart audit. No control.Baseline (n=50) and post-LCP (n=50) chart audit.Small sample precludes statistical analysis. 20% improvement in 9/16 areas after LCP implementation.IV
      • Designated funds
      • Steering committee
      • Project nurse
      • Staged implementation across 18 clinical areas
      • Education
      • Support
      • Evaluation
      • Clinical leadership
      Grogan et al. 2005
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      United KingdomImpact of ICP on EOL prescribing in a specialist palliative care unit.Retrospective audit. No control.Retrospective chart audit (n=68).Descriptive statistics only. Agitation most unstable symptom. Median dose of drugs in syringe driver did not change between LCP commencement and death for all symptoms and drugs.VLCP used to evaluate symptom management
      Kass and Ellershaw, 2003
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
      United KingdomPeople who died on the LCP in a specialist palliative care unit with RTS.Noncontrolled retrospective trial.Sample (n=202).Risk factors for RTS: male (P=0.034), lung cancer (P=0.003), and prolonged dying (P=0.001). 59% people with RTS given hyoscine. 35.5% died with RTS and 18.6% had no RTS-free period.IVLCP used to evaluate symptom management
      Jack et al. 2004
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      United KingdomUse of LCP for people who die in an acute stroke unit.Retrospective noncontrolled baseline and post-LCP chart audit.Baseline 2001–02 (n=20) and post-LCP 2002–03 (n=20) on a U.K. stroke unit.Descriptive statistics. Small sample sizes. Improvements observed in 6/7 key areas assessed.VAudit undertaken by research team
      Jack et al. 2003
      • Jack B.A.
      • Gambles M.
      • Murphy D.
      • Ellershaw J.E.
      Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting.
      United KingdomAcute care nurses perceptions of the LCP.Focus groups (n=2) and semistructured interview (n=1).Sample (n=15)Perception that LCP enhances EOL care by improving symptom control and communication with relatives/carers; increases EOL knowledge and confidence; and promotes more streamlined documentation of care needs and delivery.QE
      Fowell et al. 2002
      • Fowell A.
      • Finlay I.
      • Johnstone R.
      • Minto L.
      An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.
      United KingdomUse of LCP died in four distinct care settings: acute care, hospices, specialist inpatient units, and community care.Retrospective benchmarking of LCP.First 500 variances comparing four sites: acute care (n=133), hospices (n=185), specialist inpatient units (n=104), and community care (n=78).Descriptive statistics only. No recorded variance for 50%, implying symptoms controlled. Differences in variance rates across care settings.V
      • Centralized audit process
      • Benchmarking
      Ellershaw et al. 2001
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      United KingdomImpact of LCP on EOL symptom management in an inpatient hospice unit in a hospital.Baseline LCP audit.Inpatients (n=168)Increased length of time on ICP associated with better pain and agitation control (P<0.01).V
      LCP=Liverpool Care Pathway; EOL=end-of-life; ICP=integrated care pathway; KPIs=key performance indicators; PCAD=Palliative Care for Advanced Disease Pathway; RTS=respiratory tract secretions; SCP=Supportive Care Pathway.
      Evidence levels: I,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      systematic review of all relevant randomized controlled trials; II,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      at least one properly designed randomized controlled trial; III-1,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      well-designed pseudo-randomized controlled trials; III-2,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      comparative studies with concurrent controls and allocation not randomized, case-control studies or interrupted time series with a control group; III-3,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group; IV,

      National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, Australia: Commonwealth of Australia. Available from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp30.pdf. Accessed February 3, 2011.

      case series, either post-test or pretest and post-test; V,
      • Stetler C.B.
      • Morsi D.
      • Rucki S.
      • et al.
      Utilization-focused integrative reviews in nursing service.
      case report or systematically obtained verifiable quality or program evaluation data; QE,
      • Australian Department of Health and Ageing and National Health and Medical Research Council
      Guidelines for a palliative approach in residential aged care—Enhanced version.
      qualitative evidence.
      Table 2Summary of Study Design, Populations, Settings, and Implementation Features
      FeaturesSource
      Design
       Prepathway chart audit
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      ,
      • Hardy J.R.
      • Haberecht J.
      • Maresco-Pennisi D.
      • Yates P.
      Audit of the care of the dying in a network of hospitals and institutions in Queensland.
       Pre- and post-test pathway chart audit
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      ,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      ,
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      ,
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
       Post-test pathway chart audit
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      ,
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
       Benchmarking
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      ,
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      ,
      • Fowell A.
      • Finlay I.
      • Johnstone R.
      • Minto L.
      An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
       Symptom control audits
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      ,
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      ,
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
       Survey—health professionals
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      ,
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      ,
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
       Survey—carers
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      ,
      • Mullick A.
      • Beynon T.
      • Colvin M.
      • et al.
      Liverpool Care Pathway carers survey.
      ,
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
       Prospective consent
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
       Statistics reported
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      ,
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      ,
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
       Matched sample
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      ,
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
       Controlled
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
       Qualitative studies
      • Jack B.A.
      • Gambles M.
      • Murphy D.
      • Ellershaw J.E.
      Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting.
      ,
      • Gambles M.
      • Stirzaker S.
      • Jack B.A.
      • Ellershaw J.E.
      The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions.
      Populations
       Malignant
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
       Nonmalignant
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
       Geriatric
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      ,
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
       Mixed (malignant, nonmalignant, and geriatric)
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      ,
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      ,
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      ,
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      ,
      • Gambles M.
      • Stirzaker S.
      • Jack B.A.
      • Ellershaw J.E.
      The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions.
      ,
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      ,
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      ,
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      ,
      • Hardy J.R.
      • Haberecht J.
      • Maresco-Pennisi D.
      • Yates P.
      Audit of the care of the dying in a network of hospitals and institutions in Queensland.
      ,
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      ,
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      ,
      • Fowell A.
      • Finlay I.
      • Johnstone R.
      • Minto L.
      An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      Settings
       Acute care
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      ,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Jack B.A.
      • Gambles M.
      • Murphy D.
      • Ellershaw J.E.
      Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting.
      ,
      • Mullick A.
      • Beynon T.
      • Colvin M.
      • et al.
      Liverpool Care Pathway carers survey.
      ,
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      ,
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
       Palliative care unit or hospice
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      ,
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      ,
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      ,
      • Gambles M.
      • Stirzaker S.
      • Jack B.A.
      • Ellershaw J.E.
      The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions.
      ,
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      ,
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      ,
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
       Mixed (acute, hospice, and community)
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      ,
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      ,
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      ,
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      ,
      • Fowell A.
      • Finlay I.
      • Johnstone R.
      • Minto L.
      An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      Implementation features
       Clinical champion
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
       Facilitator
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
       Education
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
       Defined performance indicators
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
       Quality Improvement approach
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      ,
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
       Modified pathway
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      ,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      ,
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
       In-house audit process (nonresearch team audit)
      • Hardy J.R.
      • Haberecht J.
      • Maresco-Pennisi D.
      • Yates P.
      Audit of the care of the dying in a network of hospitals and institutions in Queensland.
      ,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      ,
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.

      Populations and Settings

      Fifteen studies were conducted in the United Kingdom, four in The Netherlands, three in the United States, two in Australia, and one each in Ireland and China. Although end-of-life care pathways were originally intended for cancer populations, only four studies focused exclusively on people dying with cancer. Three studies examined the impact of the pathway on care for people dying from other causes, such as stroke, renal failure, postcardiac arrest, or an intracranial hemorrhage. Eleven studies reported on pathway data related to the care of people dying in a range of acute care settings, and seven studies were undertaken in a palliative care or hospice environment. Four studies outlined pathway modifications, including tailoring end-of-life care for specific populations,
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      increasing the observation period to manage workforce issues,
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      expanding the time period that death was predicted to occur within seven days,
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      and maintaining active treatment.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.

      Qualitative Studies

      Four qualitative studies focusing on end-of-life care pathway domains reported findings from focus group
      • Jack B.A.
      • Gambles M.
      • Murphy D.
      • Ellershaw J.E.
      Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting.
      and semistructured interviews.
      • Gambles M.
      • Stirzaker S.
      • Jack B.A.
      • Ellershaw J.E.
      The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions.
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.
      These studies all tended to be undertaken early in the pathways evolution. The key themes emerging from these qualitative studies revealed a perception that the end-of-life care pathway had impacted positively on care of the dying through better coordination of care, enhanced communication, and greater adherence to evidence-based clinical guidelines (Level QE).
      • Jack B.A.
      • Gambles M.
      • Murphy D.
      • Ellershaw J.E.
      Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting.
      • Lhussier M.
      • Carr S.M.
      • Wilcockson J.
      The evaluation of an end-of-life integrated care pathway.

      Health Professional and/or Carer Perceptions

      Six studies reported health professional
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      or carer survey data
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Mullick A.
      • Beynon T.
      • Colvin M.
      • et al.
      Liverpool Care Pathway carers survey.
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      on various aspects of end-of-life care pathway usage. There was some evidence (Level IV) that the use of an end-of-life care pathway contributed to lower levels of bereavement in relatives
      • Veerbeek L.
      • van der Heide A.
      • de Vogel-Voogt E.
      • et al.
      Using the LCP: bereaved relatives’ assessments of communication and bereavement.
      and lower levels of perceived patient symptom burden in the last days of life.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.

      Pre- and/or Post-Pathway Audits

      Nearly all studies identified in this end-of-life care pathway integrated review were nonexperimental studies that reported baseline and post-pathway implementation chart audits.
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      • Hinton V.
      • Fish M.
      A care pathway for the end of life in a renal setting.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      Few of these pre- and post-test chart audit studies included a control group
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      • Luhrs C.A.
      • Meghani S.
      • Homel P.
      • et al.
      Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.
      or collected contemporaneous data,
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.
      and only one study matched the groups.
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      A subset of chart audit studies reported just baseline
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      • Hardy J.R.
      • Haberecht J.
      • Maresco-Pennisi D.
      • Yates P.
      Audit of the care of the dying in a network of hospitals and institutions in Queensland.
      or post-pathway chart audit data.
      • Jackson K.
      • Mooney C.
      • Campbell D.
      The development and implementation of the pathway for improving the care of the dying in general medical wards.
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      The baseline pathway chart audit data confirmed previous reports that people dying in the acute care sector experience varying levels of care depending on who was responsible for managing the dying process.
      • Al-Qurainy R.
      • Collis E.
      • Feuer D.
      Dying in an acute hospital setting: the challenges and solutions.
      • Parish K.
      • Glaetzer K.
      • Grbich C.
      • et al.
      Dying for attention: palliative care in the acute setting.
      Inadequate symptom management and poor communication within the multidisciplinary team and with patients and their families were noted.
      • Mellor F.
      • Foley T.
      • Connolly M.
      • Mercer V.
      • Spanswick M.
      Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.
      The majority of these chart audits involved small sample sizes, reflecting a quality improvement approach, which limited data analysis to descriptive statistics only. A pre-post test pathway study with a larger sample noted some positive changes in end-of-life care delivery but, because of inability to control for confounders, was unable to confirm whether the pathway actually drove improvements in care of the dying.
      • Bookbinder M.
      • Blank A.E.
      • Arney E.
      • et al.
      Improving end-of-life care: development and pilot-test of a clinical pathway.
      Another large pre-post test pathway study found that the intervention improved end-of-life care, with an increase in the mean number of symptoms documented, comfort care plans implemented, and opioid and “do not resuscitate” (DNR) orders (P<0.001).
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      However, this same study also reported an increase in the use of restraints (P<0.001), which is not reflective of best practice end-of-life care.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      A mixed methods study using pre-post pathway chart audits and carer follow-up obtained patient consent demonstrating that prospective end-of-life care pathway studies are indeed possible.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      Most studies provided details of the chart audit selection process, but few defined the criteria by which “expected to die” was determined.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      It is estimated that approximately 50% of deaths in acute care cannot be predicted, and it can be assumed that only half of all retrospective baseline chart audit records would contain information suggesting that the patient’s death was expected.
      • Gibbins J.
      • McCoubrie R.
      • Alexander N.
      • Kinzel C.
      • Forbes K.
      Diagnosing dying in the acute hospital setting—are we too late?.
      These end-of-life prognostication challenges may account for some of the suboptimal pre-pathway implementation results.
      • van der Heide A.
      • Veerbeek L.
      • Swart S.
      • et al.
      End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP.

      Retrospective Symptom Management

      Three studies reported retrospective symptom management pathway data.
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
      A matched sample study without a control compared retrospective and prospective pathway data to determine the effectiveness of various medications to manage respiratory tract secretions.
      • Hugel H.
      • Ellershaw J.
      • Gambles M.
      Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide.
      One other study retrospectively examined the impact of the pathway on physician prescribing,
      • Grogan E.
      • Peel L.M.
      • Peel E.T.
      Drugs at the end of life: does an integrated care pathway simplify prescribing?.
      whereas another described the profile of people who experienced excessive respiratory tract secretions at the end of life.
      • Kåss R.M.
      • Ellershaw J.
      Respiratory tract secretions in the dying patient: a retrospective study.
      These studies suggest that end-of-life care pathway clinical data could be used to determine feasibility and design larger prospective multicenter controlled trials.

      Benchmarking

      The widespread uptake of the end-of-life care pathway has enabled benchmarking studies involving local,
      • Fowell A.
      • Finlay I.
      • Johnstone R.
      • Minto L.
      An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care.
      national,
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      or international
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      comparisons to be undertaken. There may be scope for further larger benchmarking studies that would allow for more robust evaluation of the impact of end-of-life care pathways on care outcomes at the patient, health professional, and system level, across jurisdictions.

      Implementation Issues

      Some of the key strengths of the end-of-life care pathway (Table 3) include a perception that it increased the accessibility of palliative care outside of specialist services or units
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      and promoted the adoption of best evidence-based end-of-life care regardless of care setting or competencies.
      • Ellershaw J.
      • Smith C.
      • Walker S.E.
      • Aldridge J.
      Care of the dying: setting standards for symptom control in the last 48 hours of life.
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Veerbeek L.
      • van Zuylen L.
      • Swart S.J.
      • et al.
      The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Jack C.
      • Jones L.
      • Jack B.A.
      • et al.
      Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      The capacity of the pathways to act as a template to guide the delivery of care in the last hours or days of life, regardless of setting, appears to have propelled the pathways’ widespread adoption. The appointment of an experienced nurse as the pathway facilitator for 12–18 months,
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      • Mellor F.
      • Foley T.
      • Connolly M.
      • Mercer V.
      • Spanswick M.
      Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.
      selecting acute care wards with a significant burden of death, and piloting the pathway in units with high-level clinical support
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      also were singled out as important success factors.
      • Mellor F.
      • Foley T.
      • Connolly M.
      • Mercer V.
      • Spanswick M.
      Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.
      In the large U.K. benchmarking studies, hospitals with a pathway facilitator were noted to have higher pathway compliance levels.
      The Marie Curie Palliative Care Institute Liverpool in collaboration with the Clinical Standards Department of the Royal College of Physicians
      National care of the dying audit—hospitals: Generic report 2008/2009.
      • The Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians Clinical Effectiveness & Evaluation Unit
      National care of the dying audit—hospitals (NCDAH)—Summary report.
      Table 3Strengths and Weaknesses of Using an End-of-Life Care Pathway in the Acute Care or Hospice Setting
      StrengthsWeaknesses
      • Promotes the adoption of best evidence-based care for the dying regardless of setting and clinician competencies
        • Ellershaw J.
        • Smith C.
        • Walker S.E.
        • Aldridge J.
        Care of the dying: setting standards for symptom control in the last 48 hours of life.
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
        • Jack C.
        • Jones L.
        • Jack B.A.
        • et al.
        Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
        • Mirando S.
        • Davies P.D.
        • Lipp A.
        Introducing an integrated care pathway for the last days of life.
      • Increases the accessibility of palliative care outside of specialist services and/or units
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
        • Jack C.
        • Jones L.
        • Jack B.A.
        • et al.
        Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      • Structures care and promotes proactive management of patient comfort
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
        • Veerbeek L.
        • van der Heide A.
        • de Vogel-Voogt E.
        • et al.
        Using the LCP: bereaved relatives’ assessments of communication and bereavement.
        • Ellershaw J.
        • Ward C.
        Care of the dying patient: the last hours or days of life.
      • Clarifies the goals of care with the patient, family, and care team
        • Veerbeek L.
        • van Zuylen L.I.A.
        • Gambles M.
        • et al.
        Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Promotes more effective multidisciplinary communication (patient, family, and care team)
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Actively engages patients and families in decision making
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Promotes patient-centered care
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Provides a framework for addressing previously challenging care issues
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Implementation requires high-level organizational support
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Mirando S.
        • Davies P.D.
        • Lipp A.
        Introducing an integrated care pathway for the last days of life.
      • Acts as a quality improvement and benchmarking framework and audit tool
        • Ellershaw J.
        • Smith C.
        • Walker S.E.
        • Aldridge J.
        Care of the dying: setting standards for symptom control in the last 48 hours of life.
        • Veerbeek L.
        • van Zuylen L.I.A.
        • Gambles M.
        • et al.
        Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Reduces documentation requirements
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Assists to identify further areas for research
        • Veerbeek L.
        • van Zuylen L.
        • Swart S.J.
        • et al.
        The effect of the Liverpool Care Pathway for the dying: a multicenter study.
      • Aligns care delivered with policy
        • Jack C.
        • Jones L.
        • Jack B.A.
        • et al.
        Towards a good death: the impact of the care of the dying pathway in an acute stroke unit.
      • Can be readily translated into other languages
        • Swart S.
        • van Veluw H.
        • van Zuylen L.
        • Gambles M.
        • Ellershaw J.
        Dutch experiences with the Liverpool Care Pathway.
        • Veerbeek L.
        • van Zuylen L.I.A.
        • Gambles M.
        • et al.
        Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      • Absence of evidence from a randomized controlled trial
        • Shah S.H.
        The Liverpool Care Pathway: its impact on improving the care of the dying.
        • Chan R.
        • Webster J.
        End-of-life care pathways for improving outcomes in caring for the dying.
      • Developed for a cancer population
        • Ellershaw J.
        • Smith C.
        • Walker S.E.
        • Aldridge J.
        Care of the dying: setting standards for symptom control in the last 48 hours of life.
      • Modification may be required for a noncancer population
        • Ellershaw J.
        • Smith C.
        • Walker S.E.
        • Aldridge J.
        Care of the dying: setting standards for symptom control in the last 48 hours of life.
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Dependent on timely recognition and diagnosing of dying—only 50% of deaths in acute care are predicted
        • Veerbeek L.
        • van Zuylen L.I.A.
        • Gambles M.
        • et al.
        Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
        • Main J.
        • Whittle C.
        • Treml J.
        • Woolley J.
        • Main A.
        The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      • Poorly defined death indicators
        • Bailey F.A.
        • Burgio K.L.
        • Woodby L.L.
        • et al.
        Improving processes of hospital care during the last hours of life.
      • Implementation challenging in a “cure culture”
        • Ellershaw J.
        • Smith C.
        • Walker S.E.
        • Aldridge J.
        Care of the dying: setting standards for symptom control in the last 48 hours of life.
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Not linked to a palliative care pathway, which ought to be commenced well before the last 72 hours of life
        • Main J.
        • Whittle C.
        • Treml J.
        • Woolley J.
        • Main A.
        The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      • Requires strong clinical leadership with the capacity to devote the time and capacity required to successfully lead the change process and provide ongoing monitoring
        • Bailey F.A.
        • Burgio K.L.
        • Woodby L.L.
        • et al.
        Improving processes of hospital care during the last hours of life.
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
        • Mirando S.
        • Davies P.D.
        • Lipp A.
        Introducing an integrated care pathway for the last days of life.
      • A financial commitment and support to
      • 1.
        establish designated pathway facilitators
        • Mirando S.
        • Davies P.D.
        • Lipp A.
        Introducing an integrated care pathway for the last days of life.
      • 2.
        provide the necessary learning opportunities required for clinicians to be confident about diagnosing dying and using the pathway
        • Paterson B.C.
        • Duncan R.
        • Conway R.
        • et al.
        Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.

      Discussion

      This integrative review did not identify any randomized controlled trials, and most studies provided low levels of evidence for the pathway’s effectiveness, despite its widespread adoption. Notwithstanding this limitation, the end-of-life care pathway has been used for a range of dying populations in a variety of acute and hospice care settings across much of the developed world. However, the lack of evidence from pragmatic clinical trials means that only low-level evidence is available to support the use of the end-of-life care pathway in the acute care and/or hospice settings.
      It is currently estimated that only 50% of deaths in acute care can be accurately predicted.
      • Gibbins J.
      • McCoubrie R.
      • Alexander N.
      • Kinzel C.
      • Forbes K.
      Diagnosing dying in the acute hospital setting—are we too late?.
      • Veerbeek L.
      • van Zuylen L.I.A.
      • Gambles M.
      • et al.
      Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital.
      • Main J.
      • Whittle C.
      • Treml J.
      • Woolley J.
      • Main A.
      The development of an Integrated Care Pathway for all patients with advanced life-limiting illness—the Supportive Care Pathway.
      The lack of universally accepted and validated criteria by which dying can be accurately predicted in different populations may impact on health professionals’ preparedness to initiate an end-of-life care pathway. Implementing an end-of-life care pathway is predicated on recognition of dying and multidisciplinary team agreement that there are no potentially reversible causes for the patient’s decline that need to be addressed.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      Alternatively, the ability to predict death also may reflect the fluctuating trajectories of people dying from organ failure and the slow dwindling trajectories associated with dementia and frailty, which make diagnosing dying in these populations a complex process and an inexact science.
      • Lynn J.
      • Adamson D.M.
      Living well at the end of life: Adapting health care to serious chronic illness in old age.
      • Murray S.A.
      • Kendall M.
      • Boyd K.
      • Sheikh A.
      Illness trajectories and palliative care.
      Although the end-of-life care pathway may be applicable in the final days of life, it does not preclude advance care planning early in the illness trajectory and may in fact demonstrate the significance of this issue in priming the patient, clinician, and health care system for reform.
      • National Health and Hospitals Reform Commission
      A healthier future for all Australians.
      Several studies provide insights into strategies that supported the implementation of the pathway and drive practice change. Clinical education sessions, strong clinical leadership,
      • Paterson B.C.
      • Duncan R.
      • Conway R.
      • et al.
      Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      and the presence of a pathway facilitator
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      were all identified as critical success factors, as well as health professionals having the necessary competencies to initiate and use the pathway.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      • Mellor F.
      • Foley T.
      • Connolly M.
      • Mercer V.
      • Spanswick M.
      Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.
      One implementation study tapped into a larger external physician education program on end-of-life care and provided education on a continuous cycle to manage junior staff rotations.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      All learning sessions were repeated frequently to increase clinicians’ competencies and assist with embedding change.
      • Bailey F.A.
      • Burgio K.L.
      • Woodby L.L.
      • et al.
      Improving processes of hospital care during the last hours of life.
      Managing perceptions that the introduction of the pathway would be an additional documentation burden and workload for clinicians is an important aspect of the implementation process.
      • Mellor F.
      • Foley T.
      • Connolly M.
      • Mercer V.
      • Spanswick M.
      Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.
      The palliative care capabilities of the pathway facilitator appear to be central to ensuring that the dying patient’s transition onto the pathway is appropriately negotiated and safely managed. The pathway facilitator also plays a key role in building the palliative care capacity of health professionals. Despite this positive relationship, the number of U.K. pathway facilitators actually decreased over time, reflecting a trend to use facilitators for a defined period during the pathway implementation phase.
      • Mirando S.
      • Davies P.D.
      • Lipp A.
      Introducing an integrated care pathway for the last days of life.
      Yet, what is not known is whether appropriate pathway usage can be sustained over time, especially in the absence of a designated facilitator. This integrative review revealed that the settings effectively using the pathway had evidence of clinical leadership, access to a pathway facilitator, availability of a specialist palliative care team, a structured education program and high-level organizational support. These factors appear to be important considerations if the end-of-life care pathway is to be safely and effectively used by nonspecialist palliative care to provide best evidence-based care to dying people.
      There was limited acknowledgment in these studies of the need for ongoing evaluation of the pathway’s effectiveness. Few studies explicitly stressed the critical importance of integrating individual clinical expertise and critical decision making into end-of-life care delivery. Strengthening this linkage is critical if the end-of-life care pathway is to be safely and effectively implemented in the context and manner in which it was intended to be used. This is particularly important given the global focus on extending best evidence-based care to dying people, regardless of care setting.

      Limitations

      Only studies in English were accessible for this review, and issues relating to publication bias need to be considered. Furthermore, given the resource limitations of this review, no attempts were made to access research reported in the gray literature. These methodological limitations make it difficult to fully evaluate the impact of the end-of-life care pathway on care of the dying. However, the barriers to undertaking randomized controlled trials in palliative care are well noted,
      • Aoun S.M.
      • Kristjanson L.J.
      Challenging the framework for evidence in palliative care research.
      and this does not mean that the lessons learned from these studies are not valuable in improving future care.

      Implications for Future Research

      The challenge of undertaking end-of-life care research is well documented.
      • Aoun S.M.
      • Kristjanson L.J.
      Challenging the framework for evidence in palliative care research.
      This underscores the importance of using pragmatic clinical trial considerations. To date, few studies have been able to accurately define imminent dying, describe the perceptions and experiences of the families and carers with the end-of-life care pathway, or explain the impact of care pathways on long-term bereavement outcomes. Greater understanding of the facilitator role also is required to gain insights into the degree to which this position bridges the gap between health professionals’ palliative care capabilities and their ability to effectively determine when the use of an end-of-life care pathway is indicated. Further research also is needed to determine whether safe and effective pathway usage can be sustained over time, especially in the absence of a designated facilitator. It also is important to consider the cultural aspects of death and, therefore, international comparisons of outcomes would be of particular interest.
      • Lo S.H.
      • Chan C.Y.
      • Chan C.H.
      • et al.
      The implementation of an end-of-life integrated care pathway in a Chinese population.
      Because the use of end-of-life care pathways has become more widespread, several benchmarking studies have emerged; yet, the process for setting these benchmarks is unclear. Using systematic approaches for developing benchmarks, deriving consensus, and endorsement by policy and professional bodies is warranted.
      • Jaeschke R.
      • Guyatt G.H.
      • Dellinger P.
      • et al.
      Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive.
      • Jaeschke R.
      • Jankowski M.
      • Brozek J.
      • Antonelli M.
      How to develop guidelines for clinical practice.

      Conclusion

      End-of-life care pathways have been widely implemented over recent decades in the absence of evidence from randomized controlled trials to support their use. In spite of this limitation, this review has identified some favorable outcomes in adopting this approach, as well as barriers to implementation. Furthermore, assessment of the impact of the end-of-life care pathways within pragmatic clinical trials is recommended.

      Disclosures and Acknowledgments

      No funding was received for this study, and the authors declare no conflicts of interest.

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