Life In The Slower Lane

Here is the PICO analysis for the thirty-first uploaded article:

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✅ PICO Analysis

Full Article Title:

The Effect of Policy on End-of-Life Care Practice Within Nursing Care Homes: A Systematic Review

Type of Study:

Systematic review

Journal and Year:

Palliative Medicine (2013); 27(3):209–220

DOI: 10.1177/0269216311432899

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P – Population

• Setting:
  • Nursing care homes (NCHs) in the United Kingdom
• Participants:
  • Residents, their families, and staff in NCHs
• Scope:
  • Focused on homes providing 24-hour nursing care (not homes offering personal care only)
  • Studies involving UK-based populations only

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I – Intervention

• Nature of Interventions Evaluated:
  1. Gold Standards Framework in Care Homes (GSFCH)
     • System-based approach to optimise end-of-life care in NCHs, including Advance Care Planning (ACP)
  2. Liverpool Care Pathway (LCP) or an Integrated Care Pathway (ICP)
     • Framework for the care of people in the last days of life
  3. Educational and Training Interventions
     • Focused on palliative care practice
• Implementation Focus:
  • All interventions were driven by UK national policy encouraging better end-of-life care integration in care homes 

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C – Comparison

• Comparator:
  • Pre-intervention vs. post-intervention data within the same NCHs (no formal control groups)
  • All included studies reported comparative outcome data (before-and-after analyses)

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O – Outcomes

1. Resident Outcomes:

• GSFCH resulted in:
  • Increased use of documented ACPs and DNAR orders
  • Reduction in inappropriate hospital admissions (from 31% to 24%)
  • Reduction in inappropriate hospital bed days (from 82% to 44%)
  • More residents dying in care homes (increase from 80.9% to 88.5%)
  • Greater availability of PRN medications and anticipatory prescribing
  • Increased use of ICPs and ‘last days of life’ protocols 

2. Family Outcomes:

• Reported by staff (as proxies):
  • Improved discussions around CPR and EOL preferences
  • More families received written information pre-death (increase from 20.2% to 52.9%)

3. Staff Outcomes:

• Increased:
  • Knowledge, confidence, and use of tools like care registers and care protocols
  • Proportion of homes using GSFCH coordinators and offering structured training
• Reported rise in the perceived quality of care to both residents and family carers
• However, no studies with stand-alone educational interventions met inclusion criteria with comparative outcomes

4. ICP-Specific Outcomes:

• Reduction in:
  • Antibiotic use in last days of life (from 33% to 5%)
  • Non-essential medications
• Improvement in:
  • Symptom control for agitation, pain, and respiratory secretions (all recorded at 100% post-intervention) 

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Outcome Classification

• Person-centred outcomes:
  • Improved ACP documentation, preferred place of death, symptom control
• Process outcomes:
  • Enhanced staff training, protocol usage, interdisciplinary documentation, end-of-life care coordination
• Health system outcomes:
  • Reduced hospitalisations and inappropriate emergency admissions at end-of-life

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Summary Conclusion

This systematic review of UK policy-driven end-of-life care interventions in nursing care homes found modest but promising evidence for improved outcomes associated with the Gold Standards Framework in Care Homes (GSFCH) and Integrated Care Pathways (ICPs). These included better documentation of preferences, increased in-place death rates, and reduced avoidable hospital transfers. While outcomes suggested improved care processes and staff capabilities, the evidence base was limited by non-randomised designs, lack of control groups, and absence of long-term follow-up. No comparative data were found for education/training interventions alone. The review highlights a need for higher-quality implementation research, ideally with defined, standardised outcome measures .

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