End of life care pathway evidence based or just a good idea 2011

End-of-life care pathways? Evidence-based or ‘just a good idea’ RBWH Symposium 2011: 

End-of-life care pathways? Evidence-based or ‘just a good idea’ RBWH Symposium 2011

Slide 2: 

Joan Webster Clinical Professor Nursing Director (Research) Royal Brisbane and Women’s Hospital

Overview of presentation: 

Overview of presentation Background Findings Discussion

Overview of presentation: 

Overview of presentation Background

Background: 

Background Clinical Pathways: A form of cookbook medicine that many perceive as an appropriate tool that contributes to quality management, cost-cutting and patient satisfaction. The use of clinical pathways are very prevalent in the hospitals in many countries. Clinical pathways appeared to be effective in reducing hospital complications and improved documentation. Saint et al 2003, Rotter et al 2008 & 2009

Background: 

Background Cochrane review investigating the effects of hospital clinical pathways 5- Surgical settings 2- Critical settings 20- Medical settings Rotter et al 2009 Study Type Number of studies RCTs 19 (2  Clustered RCTs) Controlled before and after studies 4 Controlled clinical trials 2 Interrupted time series studies 2

Background: 

Background End-of-life care pathways The Liverpool Care Pathway (LCP) designed to improve care of cancer patients in the last 48 hours of life facilitate monitoring of the level and type of end-of-life care provided. 18 goals of care Different types/versions of end-of-life care pathways: E.g. Bookbinder 2005, Fowell 2002, Pooler 2003, Reymond 2011…

The widespread of end-of-life care pathways: 

The widespread of end-of-life care pathways Recommended in the national end-of-life policies in the UK and Australia > 1,800 registered users of the Liverpool Care Pathway in the UK alone. Now, its used in different languages, in different part of the world. (Marie Curie Palliative Care Institute Liverpool, 2009, DoH 2008 & DoHA 2011)

Slide 10: 

Findings

Findings of the Cochrane systematic reviews: 

Findings of the Cochrane systematic reviews Randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs and controlled before and after studies 920 titles and abstracts were located No studies fulfilled the study eligibility criteria No studies (including all relevant papers) have measured harms The effects of the EOLCP cannot be ascertained with the low level of evidence currently available. Chan et al 2010

Excluded studies: 

Excluded studies These excluded studies have a number of methodological limitations and high risks of bias Study Type Number of studies excluded Uncontrolled before and after studies 5 Clinical audits 9 Qualitative studies 4 Review articles (non-systematic reviews) 1 Other (Letter/Survey/ Case report) 6 Controlled before and after studies (poor quality) 3 Chan et al 2010, Constantini et al 2011

Acknowledging the challenges, yet, we gotta do better : 

Acknowledging the challenges, yet, we gotta do better Challenges (ethical and methodological) Difficult patient recruitment Patients too ill to participate or unable to give informed consent Heterogeneous nature of the palliative populations A number of strategies can be employed to make trials possible in palliative care Addington-Hall 2007, Karlawish 2003, Fowell 2004, Shelby-James 2011

It is not impossible…: 

It is not impossible… An Italian Cluster RCT is underway Expected final analysis: Aug 2012 16 couples of General medical wards were randomised (8 for receiving LCP and 8 controls). Baseline assessment completed for all 16 wards. Effectiveness assessment completed for 6 wards, ongoing for 8 wards and to be started for 2 wards. LCP implementation complied in 7 wards out of the 8 planned. The last one is ongoing. Constantini et al 2011, Constantini (study in progress)

Slide 15: 

Discussion

Controversies re. EOLCP: 

Controversies re. EOLCP

Controversies re. EOLCP: 

Controversies re. EOLCP “Under these guidelines, patients can have fluid and drugs withdraw while on continuous sedation until they die. In a letter to this newspaper last week, experts in palliative care raised concern about this system, highlighting that this approach can mask the signs of improvement. They argued that “forecasting death” is an inexact science…” “Any doctor knows that the decision to withdraw treatment is an incredibly complex one, involving professionals from a wide range of disciplines including a palliative care team, and can never be as simple as filling out a sheet on a clipboard…” Sep 2009

Other things that need thinking through?: 

Other things that need thinking through? Dependent on timely recognition and diagnosing of dying (only 50% of deaths in acute care are predicted) Implementation is challenging and costly Requires strong clinical leadership with a capacity required to successfully lead the change process and provide ongoing monitoring Requires sustainable education Bailey 2005, Main 2006, Paterson 2009, Phillips 2011, Veerbeek 2006

Other things that need thinking through?: 

Other things that need thinking through? A financial commitment for designated pathway facilitators learning opportunities for clinicians to be confident about diagnosing dying and using the pathway. Evidence is needed to ascertain that we are providing cost-effective care Mirando 2005, Paterson 2009, Phillips 2011

Discussions: 

Discussions “Palliative care professionals indeed can (and do) cause harm” by our care , “but fail to measure it accurately” “A national rollout of an insufficiently evaluated practice can impede the conduct of research and may be ethically flawed .” “We argue that policy makers may not have fully considered the existing evidence before rolling out the policy.” Currow 2010, Currow 2011, Chan & Webster 2011a

More than instigations…: 

More than instigations… “With the recent concerns regarding potential harms associated with the use of the EOLCP, it is important that health professionals document and report any suspected safety concerns or adverse effects associated with the pathways to their safety and quality committee in their organisations.” “ What is it about the end-of-life care pathway that has generated a frenzy of uptake well outside its original scope without due evaluation and despite significant sustained concerns at the way that it is being implemented in health care more broadly? “ There is a need to understand the reasons behind this in order to aid the uptake of new knowledge where strong evidence supports change in clinical practice or health policy.” Chan & Webster 2011b, Currow 2011

End-of-life care pathways? Evidence-based or ‘just a good idea’: 

End-of-life care pathways? Evidence-based or ‘just a good idea’

Acknowledgement: 

Acknowledgement Adj Associate Professor Alanna Geary Nursing Director Cancer Care Services, RBWH Associate Professor Roger Allison Executive Director Cancer Care Services, RBWH

References: 

References Chan R , Webster J. End-of-life care pathways for improving outcomes in caring for the dying (Review). Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD008006. DOI:10.1002/1451858.CD008006. Chan R, Webster J. (2011) A national roll out of an insufficiently evaluated practice: how evidence based are our end-of-life care policies? Journal of Palliative Medicine . 14 (7): 802. Chan R, Webster J. (2011) A Cochrane review on the effects of end of life care pathways: Do they improve patient outcomes? Australian Journal of Cancer Nursing . Inpress Constantini M, Leo SD, Beccaro M (2011) Methodological issues in a before-after study design to evaluate the Liverpool Care Pathway for the Dying Patient in hospital. Palliative Medicine (Inpress) Constantini M, Ottonelli S, Canavacci L, Pellegrini P, Beccaro M (2011) The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial. BMC Health Services Research 11:13 Currow D (2010) Why don’t we do more rigorous clinical research so that we can stop experimenting on patients? Journal of Palliative Medicine . 13: 636-637.

References: 

References Currow D (2011) Evidence-based policy. Journal of Palliative Medicine . 14 (7): 803. Main J, Whittle C, Treml J, Woolley J, Main A. 2006. The development of an Integrated Care Pathway for all patients with advanced life-limiting illness- the Supportive Care Pathway. Journal of Nursing Management 14:521-528 Mirando S, Davies P, Lipp A (2005). Introducing an integrated care pathway for the last days of life . Palliative Medicine 19:33-39 Paterson BC, Duncan R, Conway R et al (2009). Introduction of the Liverpool Care Pathway for end of life care to emergency medicine. Journal of Emergency Medicine 26:777-779. Phillips J, Halcomb E, Davidson P (2011) End-of-life care pathways in acute and hospice care: an integrative review. Journal of Pain and Symptom Management . 41 (5) 940-954 Reymond L, Israel F, Charles F (2011). A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities. Australian Health Review . 25 (3) 350-356. Veerbeek L, van Zulen LIA, Gambles M, et al. (2006) Audit of the Liverpool Care Pathway for the Dying Patient in a Dutch cancer hospital. Journal of Palliative Care. 22: 305-308