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About this publication
Liverpool Care Pathway (LCP) has been promoted as a holistic approach for the care of dying patients and their families at the end of life. We conducted this rapid review to evaluate the effectiveness of LCP on the quality of palliative care.
We included two recently published controlled studies that compared the effectiveness of LCP with standard palliative care. The results show that:
• LCP may lead to little or no difference in overall quality of care provided to dying patients and their families.
• LCP may give better symptom control in dying patients with regard to breathlessness.
• LCP may lead to a desired change in use of medications:
- higher use of one out of six possibly appropriate medications (pulmonary secretions)
- lower use of one out of ten possibly inappropriate medications (vasodilator drugs)
- increase in subcutaneous delivery of medications.
• It is uncertain if there is a difference between LCP and standard palliative care with regard to the dying patient’s physical symptoms and symptom burden at the end of life.
Available evidence regarding the effectiveness of LCP is of low to very low quality. There is a lack of high quality evidence that provides clinical documentation in favour of LCP.
In the last decades, the number of patients who die in hospitals has increased considerably. This is related to an increase in chronic diseases and an aging population. In Norway, 50 percent of patients with chronic diseases die in hospitals. In the last 20-30 years, several strategies have been launched for the improvement of palliative medicine and care at the end of life.
Liverpool Care Pathway (LCP) emerged in Great Britain in the 1990s as a holistic approach to help and assist health professionals with responsibility for caring for dying patients. LCP provides structured guidance for organising and coordinating multidisciplinary palliative care in the last days and hours of life. It entails assistance from a psychologist, physical symptom relief, communication with healthcare professionals and processing of spiritual needs. Although LCP was considered an example of good practice, and has been used in Norway since around 2005, the program has been criticised and the lack of documented effects has been highlighted. The criticism has concerned, among others, the provision of hydration, nutrition and sedation in the terminal stage. After an independent review, LCP was phased out in Great Britain in 2013. A systematic review published by Cochrane in 2013 aimed to evaluate the effects of end-of-life interventions, including LCP, but found no relevant studies for inclusion.
The Norwegian Directorate of Health requested a review of the evidence of the effects of LCP, particularly in patients with dementia.
The aim of this rapid review was to summarise the effectiveness of LCP on end-of-life care.
We searched MEDLINE from 1990 to December 2015. We included randomised controlled and non-randomised trials that compared the use of LCP with standard care or different programs for patients at the end of life. No language restrictions were applied. Outcomes of interest were quality of care, symptoms control, survival and medication use.
One reviewer screened titles and abstracts. Two reviewers extracted data and evaluated the methodological quality of the studies (risk of bias). The reviewers subsequently mapped the studies with regard to the clinical condition, participants, measures, comparisons, and results. It was not possible to pool the results due to differences in the de-sign, outcomes, and estimates.
We used GRADE (Grading of Recommendations Assessment, Development and Evaluation www.gradeworkinggroup.org) to assess the overall certainty of the evidence.
Two recently published studies met our inclusion criteria: a cluster-randomised controlled trial from Italy (published in 2014) and a controlled before-and-after study conducted in Sweden (published in 2015).
The Italian study involved 16 hospital wards with 308 cancer patients. 232 family members were interviewed. LCP was provided to patients on average for 31.5 hours.
The Swedish study evaluated the effectiveness of LCP in 19 residential care homes. The study included 379 patients and 135 family members. The sample included many patients with dementia, but data were reported for all patients, regardless of diagnosis. LCP was provided to patients on average for 67 hours.
There were several methodological weaknesses with regard to the implementation of both studies, including response rate. In addition, there was low compliance of the intervention and the training to implement LCP.
The Italian study did not detect a significant difference in the overall quality of palliative care between LCP wards and control wards (mean difference: 7.6 [95% CI -3.6 to 18.7]). However, it found effect favouring LCP in 1 of 6 sub-scales, with regards to personnel exhibiting more respect, dignity, and kindness (mean difference: 8.4 [95% CI 0.3 to16.6]). The study did not detect a significant difference in regard to overall control of pain and nausea or vomiting, but found a positive effect for LCP with regard to overall control of breathlessness (Odds Ratio [OR]: 2.0 [95% CI 1.1 to 3.8]). The results also indicated a statistically significant difference between LCP wards and control wards with regard to use of medications for pulmonary secretions (OR: 13.8 [95% CI 3.7 to 51.4]), vasodilator drugs (OR: 0.3 [95% CI 0.1 to 0.9]) and drugs given only subcutaneously (OR: 3.7 [95% CI 1.0 to 13.5]). The study did not detect a difference in regard to the other 15 outcomes for administration of drugs.
The Swedish study showed positive effects for LCP in 2 of 9 symptoms (shortness of breath -2.46 [95% CI -4.43 to -0.49] and nausea -1.83 [95% CI-3.12 to - 0.54]) compared with standard palliative care at the end of life in patients in residential care homes. The results also showed an improvement in breathlessness in the LCP group when another instrument was used (-0.47 [95% CI -0.85 to -0.08]).
A systematic Cochrane review from 2013 that deals with the effectiveness of end-of-life interventions did not find any studies for inclusion. Our rapid review identified two controlled trials that has evaluated the effects of LCP. It was a cluster randomised controlled trial from Italy and a controlled before-and-after study from Sweden. Both studies compared LCP with standard palliative care.
The results from the two studies show small or no differences between LCP and standard palliative care at the end of life. The available evidence indicates that LCP possibly can improve breathlessness in dying patients and use of some medications. However, we found no evidence that LCP is superior to standard palliative care with respect to quality of care, most of the dying patients’ physical symptoms, and prescription of palliative medications.
High overall quality of care was highlighted as one of the main objectives when LCP was launched. However, the results of available studies suggest no improvement in the overall quality of care with LCP compared to standard palliative care.
It is important to note that we have low to very low confidence in the evidence presented in this rapid review. The results therefore should be interpreted with caution. The low confidence in the estimates is mainly due to high risk of bias in the studies. The studies also enrolled few participants and there were shortcomings with regard to the implementation of the intervention. In the Italian study, only 34% of cancer patients in the intervention wards received LCP, and in the Swedish study, only 60% of patients in the intervention homes received LCP.
There is a lack of studies with low risk of bias that provide clinical evidence on the effects of LCP compared with standard palliative care for patients in the end of life. We found only two controlled studies that have evaluated the effects of LCP. The various limitations of these studies, including implementation of LCP, limit our confidence in the current evidence and the potential to draw firm conclusions.