Effects of implementation of a standardised Palliative Care Pathway for patients with advanced cancer in a hospital: a prospective pre- and post-intervention study
Early integration of palliative care in oncological care has been shown to improve quality of life in patients with advanced cancer. A Palliative Care Pathway integrated in the electronic patient record may support such integration and could guide caregivers to adapt medical care according to patients’ needs. We studied the effect of implementation of a Palliative Care Pathway on patients’ place of death, advance care planning, hospitalisations, the use of medical interventions and diagnostic procedures in the last three months of life.
In a single centre pre- and post-intervention study, data were collected for adult patients with cancer (haematological malignancies and solid tumours) who had been treated at inpatient or outpatient clinics and died between February 2014 and February 2015 (pre-PCP period) or between November 2015 and November 2016 (post-PCP period). Differences between the pre- and post-PCP period were tested with t-tests, Mann-Whitney U tests, chi-square tests or Fisher’s exact tests, where appropriate.
We included 424 patients in the pre- and 426 in the post-implementation period. The pathway was used for 237 patients (56%) in the post-implementation period, on average 33 days (IQR 12-74 days) before death. 74% and 77% of the patients died outside hospital in the pre- and post-implementation period, respectively (p=0.40). Bad-news conversations (75% and 62%,p<0.001) and preferred place of death (47% and 32%, p<0.001) were more often documented in the pre-implementation period, whereas a DNR-code was more often documented during the post-implementation period (79% and 89%,p<0.001). Hospitalisations in the last three months of life were similar. The percentage of patients that had received anticancer treatment and medical interventions was lower in the post-PCP group (40% vs 22%, P<0.001; and 76% vs 62%, p<0.001, respectively). The total number of interventions per patient was also lower in the post-PCP group. No differences were found for laboratory tests (85% vs 85%, p=0.80) or radiologic procedures (85% vs 82%, p=0.25).
Implementation of a Palliative Care Pathway had no positive effect on place of death and several aspects of advance care planning. Start of a Palliative Care Pathway in the last months of life may be too late to improve end-of-life care. However, the implementation of a PCP did resulted in less anticancer treatment and less medical interventions in the last 3 months of life. Using the PCP could support caregivers to make appropriate medical decisions in the last phase of life. In future research focus on strategies that enable earlier start of specific interventions to integrate palliative care in oncology care is needed.