Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients: a realist evaluation

Abstract

ObjectivesThe Liverpool Care Pathway (LCP) for the dying patient was designed to improve end-of-life care in generalist healthcare settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.MethodAn organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semistructured interviews were conducted with two policymakers and 22 participants with experience and/or involvement in management of the LCP during 2011 and 2012.ResultsKey resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy, and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.ConclusionsThere is a need to appreciate the organisationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships, and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

Realist evaluation: an immanent critique

“…Once again, the LCP study (McConnell et al, 2015) provides a pertinent example. At the point of project development, evaluation of the LCP had reported modest improvements in documentation and symptom burden following the introduction of the pathway (Veerbeek et al, 2008).…”

“…The importance of treating agency separately to social mechanisms can once again be seen in our realist evaluation of the LCP (McConnell et al ., ). Different agents tended to interpret changes in objective conditions that resulted from the withdrawal of facilitatory and educational resources in different ways.…”

“…Its importance lies in the need to conceptualize social mechanisms as real and external to the actors involved. Thus, for example, in our case study of the implementation of the Liverpool Care Pathway for the Dying Patient (LCP) (McConnell et al, 2015), we found that resources for ongoing training were a key mechanism for sustaining the pathway, in that training enabled clinicians to know how, why, and when to apply the pathway.When external funding for training ended, it was not replaced by internal health service investment, and formal training ceased. This had a considerably detrimental effect on the ability of clinicians to implement the pathway appropriately.…”

“…As someone with a long-standing adherence to the use of realism in nursing research (see e.g. Porter & Ryan, 1996;Porter, 2001), and who has used realist evaluation as a research framework (Higgins et al, 2014;McConnell et al, 2015), this is a welcome development. However, it has not been without its problems, the main one being healthcare researchers' difficulties in interpreting the philosophical and methodological foundations of realist evaluation (Marchal et al, 2012).…”

The possibility of critical realist randomised controlled trials

“…The relationship between the three main components highlighted by Van Belle et al might be best illustrated by an example. In a realist evaluation of the Liverpool Care Pathway for the Dying Patient [23], we noticed that the effectiveness of the pathway (intervention) was undermined by the withdrawal of educational resources to train staff in its use (context), but different actors responded to this challenge in different ways (agency), with nurses tending to continue promoting the pathway through informal education, while physicians were less committed to sustaining it.…”