Research in context
Evidence before this study
Various initiatives have been introduced worldwide to improve end-of-life care. However, there have been sustained concerns about the safety of implementing such pathways or programmes, particularly about one of the most well known—The Liverpool Care Pathway for the Dying Patient (LCP) in the UK. Therefore, clinicians and policy makers need end-of-life care programmes that are evidence based. In the most recent Cochrane review (updated search in July, 2015, of original search done in 2009), which used the search terms (“randomized controlled trial” or “controlled clinical trial” or “intervention studies/experiments” or “random”) and (”palliative care” or “palliative care” or “end-of-life” or “terminally ill” or “dying” or “hospice” or “end-stage”) and (”critical pathways” or “clinical pathway$ or care pathways” or “integrated care pathways”), only one cluster randomised trial assessing the effectiveness of the LCP was found, for patients with cancer in Italy. This trial showed no significant differences in overall quality of care between the intervention and control groups, but was statistically underpowered. The authors of the Cochrane review judged the study to be at high risk of bias overall, mainly because patients were not masked to treatment allocation and there were high rates of attrition. Thus, little evidence exists regarding the clinical, physical, psychological, or emotional effectiveness of end-of-life care pathways or programmes. No search was done for randomised controlled trials of end-of-life care programmes in intensive care units, because the intensive care unit is a different setting with different approaches to care compared with the acute geriatric hospital wards in which the intervention in our study was used.
Added value of this study
This study is, to our knowledge, the first sufficiently powered randomised controlled trial to test the effectiveness of an end-of-life care programme, the Care Programme for the Last Days of Life (CAREFuL) programme. We found a statistically and clinically significant improvement in comfort around dying assessed by nurses after implementation of the programme. We also found a significant positive effect of the programme on symptoms and care needs, but a negative effect on satisfaction with care.
Implications of all the available evidence
Our findings suggest that CAREFuL can improve the quality of dying and quality of care in acute geriatric hospital wards; however, further qualitative research is needed to gain a better understanding of the effect of CAREFuL on satisfaction with care. Further controlled implementation of the programme in acute geriatric hospital wards is likely to improve care at the end of life. Use and assessment of the programme in other settings where people are cared for at the end of life might also merit consideration.