1. Button, Elise

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Internationally, it is reported that most deaths occur in institutional settings, mainly hospitals and nursing homes.1 In these facilities, nurses are the professionals who predominantly coordinate and provide care for people in the terminal phase. In the past, dying patients in hospitals received inadequate end-of-life care, specifically symptom control and basic nursing cares.2 It was identified that improvements must be made and a holistic approach to end of life care was required to ensure dying people's comfort and dignity.2


Integrated care pathways are used in many healthcare settings to guide and standardize care for patients with a specific clinical problem.3 The Liverpool Care Pathway (LCP) is an integrated care pathway, specifically for the provision of terminal care.4,5 The pathway focuses on the physical, psychosocial, spiritual, and religious elements of end-of-life care as provided in the hospice setting.6 Nineteen essential goals are outlined in regard to caring for the dying patients and their family or carer after death.4,5 Other pathways also exist to guide care of dying people based on these principles7-9; however, the LCP is arguably the most widely used.


Internationally, end-of-life care pathways are widely used; however, the use of such pathways is controversial.10 There have been serious concerns raised regarding the safety of implementing end-of-life care pathways, particularly in the United Kingdom.11 It is essential that nurses working with dying people are aware of the evidence surrounding the use of end-of-life care pathways to inform their own practice.10



A Cochrane review was performed to assess the effects of end-of-life care pathways across all healthcare settings.12 A particular aim was to assess the effect on symptom severity and quality of life for people who were dying, or those related to the care, such as families, carers, and health professionals, or a combination of these.


Intervention of Interest

Studies were included if they compared the use of an end-of-life care pathway in caring for the dying, with usual care (no pathway), or with care guided by another type of end-of-life care pathway. Participants of the intervention were patients, carers, and families, in any healthcare setting (ie, hospital, home, or nursing home), of any age, and with any diagnosis, who received care guided by the use of an end-of-life care pathway.



A comprehensive search was conducted across the following electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, and CINAHL. Trial registries, review articles, and reference lists of relevant articles were also searched. All randomized controlled trials, quasi-randomized trials, or high-quality-controlled before-and-after studies were included. According to the standard Cochrane methodology, 2 reviewers independently screened search results using predetermined criteria, extracted data, and rated the quality of each study. Primary outcomes of interest included (1) physical symptom severity as measured by an instrument, (2) psychological symptom severity as measured by an instrument, (3) quality of life as measured by an instrument, and (4) harm or adverse events as determined by healthcare professionals, families/carers, or researchers.



Only 1 study was included in the review. This study was set in Italy and reported on a sample of 232 patients who were dying in a hospital and received informal care from family or friends.13 In this trial, 16 Italian general medicine hospital wards were randomly assigned to implement the LCP intervention or standard care. Most of the primary outcomes of interest for this review were not measured in this trial. Presence of breathlessness, pain, and nausea and vomiting was assessed. It was reported that patients receiving the LCP intervention experienced less breathlessness, compared with the standard care group. This study was judged to be of low quality because it had a high risk of bias.10 Results must be viewed with caution.



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



This review demonstrates that strong evidence supporting the use of end-of-life care pathways for dying people does not currently exist.10 Without this evidence, it is difficult to justify the implementation of end-of-life care pathways.10 End-of-life care pathways are based on previously identified gaps in care of the dying.14 It is important to note that the principles underpinning end-of-life care pathways are relevant and based on best practice holistic care.6 Palliative care is often a neglected topic in undergraduate teaching of nurses and medical students.15 Many clinicians anecdotally reported that end-of-life care pathways led to good patient outcomes because they enhanced patient-centered care and provided valuable guidance on providing terminal care.15 Neuberger et al's11 report was conducted in the United Kingdom in response to concerns voiced by the public and healthcare professionals regarding use of the LCP, specifically its use leading to premature death. This report found that a single standard approach for all patients as they near the end of life is erroneous due to the complexities and uncertainties surrounding dying.11


Clinicians are increasingly called upon to justify their practice against the best available evidence.16 However, it is argued that governments must be more willing to fund research into health service delivery before widespread adoption of an intervention as a policy.16 Certainly, in the case of end-of-life care pathways, more research is needed.10 All health services using end-of-life care pathways are encouraged to audit and review their facility's practices in light of the findings of Neuberger et al's11 report. Clinicians must be mindful that "no two patients make the same journey into the night" and end-of-life care must be individualized to the patients and their family's specific needs on all occasions.14




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