Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness

The growing number of publications in this field reflects the increasing medical and societal demand for improved end-of-life care in hospitals. Given the methodological problems involved in intervention studies, most published studies are descriptive in nature. Many were comprised of retrospective audits examining receipt of life-sustaining treatments, patient symptoms and end-of-life documentation. Others examined patient and family perceptions of care quality or health status. Few were measurement studies, which may reflect the challenges associated with measuring outcomes of effective end-of-life communication. Only 10% of the total were intervention studies.

Only 18 of the 48 intervention studies aimed at improving end of life processes met EPOC design criteria. The remainder were historical control trials, which provide potentially promising data on the feasibility and acceptability of different intervention, but require more rigorous testing. Methodological quality of the included intervention studies was variable. Particular attention needs to be paid to reporting on blinding of outcome assessment and methods of generating allocation sequence and concealing allocation.

Patient-directed interventions represent a less resource intensive approach to increasing the uptake of end-of-life processes. However, the potential reach of these interventions may be limited in hospitalised populations. Unstable patients experiencing acute illness and those lacking capacity comprise a significant proportion of hospitalised populations. This group are unlikely to utilise patient-directed interventions. In these cases, the substitute decision maker may be called on to communicate or make decisions on behalf of patients [3], so would make an appropriate alternative target for intervention. Interventions have also typically focused improving certain end-of-life processes, such as completion of ACDs, without acknowledging the potential role that other processes may play [11]. Segmenting care in this manner does not necessarily mirror the patient’s experience, nor does it recognise that end-of-life care is often synergistic and may require multiple components to be delivered to achieve a positive impact. For instance, introducing a reminder system to increase rates of end-of-life discussions is unlikely to have an impact if patients and staff lack the requisite knowledge and skills to discuss these issues effectively. Hospitals are also made up of individuals with different preferences, skills and motivation to change [6]. Therefore, relying on individuals who are willing and able to be involved in end-of-life research can bias findings. For example, the failure of the landmark SUPPORT trial has been partly attributed to a focus on improving patient-level decision-making without addressing larger, system-related challenges [36].

A more efficient and effective approach may be to support the implementation of system-level changes with potential to benefit everyone within the hospital setting. These approaches allow multiple interventions to be delivered in tandem to address deficits across a range of processes and outcomes. However, they can also pose unique challenges in relation to determining which components contribute to positive change [19]. Adopting alternative research designs, such as multiple baseline and stepped wedge designs has the potential to contribute to the evidence while maintaining methodological rigour [37].

Examining the impact of interventions on end-of-life processes alongside outcomes can provide a balanced picture of healthcare delivery, as it can help to determine whether successful implementation of an end-of-life process positively impacts end-of-life outcomes.

However, the extent to which interventions which target end-of-life processes translate to improved end-of-life outcomes is unclear. Mixed benefits of ACP and palliative care interventions were reported in relation to concordance between preferred and actual care, health status, quality of life and health care costs [11]. These findings are consistent with advance care planning reviews of studies undertaken in other care settings [12]. Reviews of palliative care interventions in ICU settings suggest that consultative approaches, in which palliative care teams consult with the treating team, may be more effective than approaches which attempt to integrate palliative care principles into the daily routines (i.e. integrative approach) [38]. Further research examining this hypothesis is warranted. Given that these interventions often rely on dedicated resources, evidence of effectiveness and sustainability within variable hospital environments must be established.

Strategies that intervene with substitute decision makers as well as patients should be explored, given likelihood of impaired capacity among hospitalised patients [39]. In particular, methodological rigorous studies examining multi-faceted, system-based interventions such as education; checklists or tools; audit and feedback and reminders should be undertaken [39]. Future research efforts should also be focused on evaluating consultative palliative care interventions that aim to ensure patients are getting the right care. Further evidence of the benefits for these more complex interventions on end-of-life outcomes, as well as their sustainability must be established.

Introducing topics such as ACP and palliative care in the community may also help alleviate pressure on hospitals. Currently, this is not done in a systematic way [40, 41]. Undertaking ACP in the community may allow preferences to be discussed and decisions made outside the context of a health crisis [42]. Increasing awareness about palliative care may lead to more positive impressions, more equitable uptake of services and improved care quality [43]. While ACP uptake is low among the general public, people are willing to discuss their views about end-of-life issues [44]. General practitioners are well placed to engage in advance care planning as they see a significant proportion of the population and will often have contextual knowledge about individuals [45]. However, lack of skills, difficulties with defining the right moment, and fear of depriving patients of hope are often cited as barriers [46]. Strategies that promote inter-professional collaboration between providers in different care settings, including primary care, hospital and residential aged care facilities, are needed [39]. Few such approaches have been rigorously evaluated.

First, the search strategy may have resulted in publication bias, as we did not include non-published studies or grey literature and there is different terminology used in different countries. Second, the authors excluded studies of provider-directed interventions when an assessment of impact on patient outcomes or processes was not included (e.g. studies that examined the impact of communication skills training interventions on provider knowledge alone). While these interactive education approaches are promising; these outcomes were not the focus and have been examined previously.