Implementation of an End-of-Life Care Pathway in Cancer Patients

Supportive care for dying hemato-oncological patients in the hospital remains an unmet need. The Liverpool Care Pathway (LCP) has been developed in Europe for patients in the final 24–72 h of life to help physicians and nurses in the end-of-life care (ELC). We evaluated appropriately timed cessation of treatment in a Hemato-Oncology Department after integration of a modified LCP in a tertiary Munich cancer center. The End-of-life Care Pathway was modified to suit local conditions. The aim of the trial was to include over 40% of dying patients in the ELC. The effectiveness of symptom control which included termination of not necessary drugs, sufficient pain relief, control of agitation, bronchial fluid secretion, dyspnoea, nausea and emesis was compared with a control group (CG). The ELC was in accordance to local ethics. Nurses and physicians were trained. The ELC was periodically reviewed by a local multidisciplinary steering group for improvements.

From 01/10 until 06/11 a total of 228 cancer deaths were observed. Criteria for entry onto the ELC were that the multidisciplinary team agreed the patient was dying, and was at least two of the following: bedbound; semi-comatose; only able to take sips of fluid; no longer able to take tablets. 96 pts (41 male/55 female) went on the ELC (42%), while 132 dying cancer pts were not enrolled due to a variety of reasons (e.g. lack of informed consent, rapid deterioration). The mean age was 72,6 ys (range 33 to 91 ys). The median duration of ELC use was 41,3 hours (range 0.5 to 189 h). Six patients improved after they had entered the ELC and left the ELC consecutively. Out of these four patients reentered the ELC and died, one of these six patients died without being reentered on the ELC. Symptom control (ELC/CG in %) was achieved in pain in 92/50%; agitation 89/50%, nausea 96/40%, dyspnoea 92/55% while unnecessary medication was terminated in 95/90%. All patients had current medication assessed and non-essential drugs were discontinued. Inappropriate interventions with antibiotics (85/65%), blood tests (95/75%), iv fluids (90/70%) were terminated more often when pts entered the ELC.

Integration of an ELC in a hematology unit provides a better symptom control for dying patients. Inappropriate interventions could be reduced. Appropriate template design and supervision are the keys to success for end-of-life care in cancer patients.

No relevant conflicts of interest to declare.