Hospice Practices Little Help in Hospital Setting

A new study reveals that quality improvement programs designed to bring lessons from the hospice to the hospital did little to improve end-of-life care or outcomes for patients dying of cancer.

Researchers at the Arcispedale S. Maria Nuova (Reggio Emilia, Italy) conducted a pragmatic cluster randomized trial involving 16 Italian general medicine hospital wards randomly assigned to implement the Liverpool Care Pathway (LCP) program for patients who are dying of cancer. The researchers identified 308 patients who died from cancer in the preintervention period and in the six months after the completion of the LCP-I training program. The primary endpoint was the overall quality of care.

The results showed that during the postintervention assessment, 232 (75%) of 308 family members were interviewed, 119 (81%) of 147 with relatives cared for in the LCP wards, and 113 (70%) of 161 in the control wards. After implementation of the LCP program, no significant difference was noted in the distribution of the overall quality of care toolkit scores between the wards in which the LCP program was implemented and the control wards. Only two of the nine family-reported outcomes—respect, dignity, and kindness; and control of breathlessness—showed any improvement with the program, while control of pain and nausea or vomiting remained about the same. The study was published ahead of print on October 16, 2013, in the Lancet.

“Our findings suggest an important continuing role for inpatient hospices and specialist palliative care units, in which the total culture of care (environment, staffing, procedures, and philosophy) differs from that in hospitals,” concluded lead author Massimo Costantini, MD, and colleagues.

The Liverpool Care Pathway for the Dying Patient has been developed to transfer the hospice model of care into other care settings. The program is recognized nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and provide support to their relatives and carers. The LCP provides a useful template to guide the delivery of care for the dying; once commenced, the goals of care prompt staff to consider the continued need for invasive procedures and whether current medications really are conferring benefit.

The healthcare professional is free to use his or her own clinical judgment in this process, and the use of the LCP does not preclude use of antibiotics or artificial nutrition or hydration, but it does ask the professional to consider an appropriate decision for that moment in time and document the reason for decisions made.

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Arcispedale S. Maria Nuova