The quality of care provided to patients with cancer who are dying in hospital and their families is suboptimum. The UK Liverpool Care Pathway (LCP) for patients who are dying was developed with the aim of transferring the best practice of hospices to hospitals. We therefore assessed the effectiveness of LCP in the Italian context (LCP–I) in improving the quality of end–of–life care for patients with cancer in hospitals and for their family.
In this pragmatic cluster randomised trial, 16 Italian general medicine hospital wards were randomly assigned to implement the LCP–I programme or standard health–care practice. For each ward, we identified all patients who died from cancer in the 3 months before randomisation (preintervention) and in the 6 months after the completion of the LCP–I training programme. The primary endpoint was the overall quality of care toolkit scale. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01081899.
During the postintervention assessment, data were gathered for 308 patients who died from cancer (147 in LCP–I programme wards and 161 in control wards). 232 (75%) of 308 family members were interviewed, 119 (81%) of 147 with relatives cared for in the LCP–I wards (mean cluster size 14.9 [range eight to 22]) and 113 (70%) of 161 in the control wards (14.1 [eight to 22]). After implementation of the LCP–I programme, no significant difference was noted in the distribution of the overall quality of care toolkit scores between the wards in which the LCP–I programme was implemented and the control wards (score 70.5 of 100 vs 63.0 of 100; cluster–adjusted mean difference 7.6 [95% CI -3.6 to 18.7]; p=0.186).
The effect of the LCP–I programme in our study is less than the effects noted in earlier phase 2 trials. However, if the programme is implemented well it has the potential to reduce the gap in quality of care between hospices and hospitals. Further research is needed to ascertain what components of the LCP–I programme might be effective and to develop and assess a wider range of approaches to quality improvement in hospital care for people at the end of their lives and for their families.
Italian Ministry of Health and Maruzza Lefebvre D'Ovidio Foundation–Onlus.