Life In The Slower Lane

Here is the standardised PICO analysis for the third uploaded article:

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Full Title

The integrated implementation of two end-of-life care tools in nursing care homes in the UK: an in-depth evaluation

Authors: J. Hockley, J. Watson, D. Oxenham, S. A. Murray

Journal: Palliative Medicine, 2010; 24(8): 828–838

DOI: 10.1177/0269216310373162

Type of Study

Mixed-methods in-depth evaluation

Includes retrospective record review, staff survey, and implementation study with pre/post comparisons.

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PICO Summary

Population (P)

• Residents of seven private nursing care homes in Midlothian, Scotland
• Total of 228 deceased residents (110 pre-implementation, 138 post-implementation)
• Age range: 66–103 years, with over one-third aged ≥90
• High frailty; 66% had dementia; most died within 2 years of admission
• Also included staff across the nursing homes (for audit)

Intervention (I)

• Integrated implementation of two end-of-life care tools:
  1. Gold Standards Framework for Care Homes (GSFCH)
  2. Adapted Liverpool Care Pathway (LCP)
• Delivered via:
  • High-intensity facilitation (visits every 10–14 days)
  • Key staff (“champions”) trained and supported
  • Monthly case review meetings
  • Scenario-based education sessions for all staff
  • ACP and DNAR discussions promoted systematically

Comparison (C)

• Pre-implementation period (12 months prior) served as the comparator
• No external control group, but baseline data were robustly analysed

Outcomes (O)

Person-centred outcomes:

• Increased staff confidence in talking about dying
• More discussions and documentation of residents’ wishes
• Shift in care culture from curative to comfort-focused care

Process outcomes:

• DNAR documentation increased from 15% to 72%
• Advance Care Planning (ACP) documentation rose from 4% to 53%
• LCP use increased from 3% to 31%
• Improved symptom documentation and family communication practices
• Changes in staff attitudes: 88% reported shift from “striving to keep alive” to quality of life focus 

Health system outcomes:

• Hospital deaths reduced from 15% to 8%
• Clinically inappropriate hospital bed-days reduced from 82% to 44%
• Decrease in overall hospital admissions in the last 8 weeks of life
• 38% reduction in hospital bed-days for dying residents

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Findings Summary

• Implementation of GSFCH and LCP tools was associated with meaningful improvements in end-of-life care practices
• Greatest success in homes with stable leadership; staff turnover remained a challenge
• Sustained culture change required ongoing facilitation and involvement from senior management
• The study supports policy recommendations to embed structured palliative care tools in nursing home settings 

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