End-of-life care pathways for improving outcomes in caring for the dying
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 18 NOV 2013
Assessed as up-to-date: 18 JUN 2013
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Chan RJ, Webster J. End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD008006. DOI: 10.1002/14651858.CD008006.pub3.
- Publication Status: Edited (no change to conclusions)
- Published Online: 18 NOV 2013
This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review.
To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).
In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013.
All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.
Data collection and analysis
Two review authors assessed the results of the searches against the predetermined criteria for inclusion.
The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update.
With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.
Plain language summary
End-of-life care pathways for the dying
End-of-life pathways are used for people who are in the last days of their life to guide care, aid decision making and provide efficient care. This review examined whether using end-of-life care pathways in caring for the dying was effective.
We searched scientific databases for clinical trials in which the effect of the end-of-life care pathway was compared with a control group that received usual care or with trials comparing one end-of-life care pathway with another end-of-life care pathway. Participants were to be patients, carers and families who received care guided by an end-of-life care pathway. There were no restrictions on age of the patient, diagnosis or setting (hospital, home, nursing home).
We found no studies fitting our criteria.
Quality of evidence
We could not locate any high-quality controlled studies that could answer this important question; despite concerns about the Liverpool Care Pathway (the most commonly used end-of-life care pathway). It is important for health services to base their care on high-quality evidence. Until such evidence is available, the use of end-of-life care pathways should be avoided. Large randomised controlled trials (where patients are allocated to treatments or groups using a random method) or other well-designed controlled studies are required for evaluating the use of end-of-life care pathways in caring for dying people in various clinical settings. Future studies should measure positive as well as negative outcomes for patients, families, carers and health professionals.