Effects of Implementation of a Standardized Palliative Care Pathway for Patients with Advanced Cancer in a Hospital: A Prospective Pre- and Postintervention Study

Context: Early integration of oncology and palliative care has been recommended to improve patient outcomes at the end of life. A standardized Palliative Care Pathway, consisting of a structured electronic medical checklist, may support such integration. Objectives: We studied the effect of implementation of a Palliative Care Pathway on patients’ place of death and advance care planning. Methods: We conducted a prospective pre- and postimplementation study of adult patients with cancer from a single hospital who died between February 2014 and February 2015 (pre-implementation period) or between November 2015 and November 2016 (post-implementation period). Results: We included 424 patients in the pre- and 426 in the post-implementation period. The pathway was started for 236 patients (55%) in the post-implementation period, on average 33 days (IQR 12-73 days) before death. 74% and 77% of the patients died outside hospital in the pre- and post-implementation period, respectively (P = 0.360). When the PCP was initiated, 83% died outside hospital. Bad-news conversations (75% and 62%, P < 0.001) and preferred place of death (47% and 32%, P < 0.001) were more often documented in the pre-implementation period, whereas a DNR-code was more often documented during the post-implementation period (79% and 89%, P < 0.001). Conclusions: Implementation of a Palliative Care Pathway had no overall positive effect on place of death and several aspects of advance care planning. Start of a Palliative Care Pathway in the last months of life may be too late to improve end-of-life care. Future research should focus on strategies enabling earlier start of palliative care interventions.