Abstract
Dear Editor:
Australia New Zealand Society of Palliative Medicine (ANZSPM) Clinical Indicators Working Group is committed to the development of a Clinical Indicator (CI) for the care of the dying.
As part of the development of such a CI, a Care-of-the-Dying Pathway (CODp) workshop was convened at the 2010 ANZSPM Conference. This brought together clinical leaders from Australia and New Zealand in Palliative Medicine to specifically examine the evidence for and relevance of pathway use for supporting terminal care.
Scoping of prevalence of pathway use indicated that throughout all states of Australia and throughout New Zealand CODp development and implementation was widespread. The majority of CODps were modified versions of the Liverpool Care Pathway. 1
There is recognition that a CODp is based on previously identified gaps in care and evidence of poor quality care.
We wish to emphasize that the CODp guides appropriate and proactive diagnosis of dying, rational deprescribing and relevant prescribing, removes the burden of unnecessary clinical interventions that may be construed as futile treatment, and prompts communication with patient and family. The pathway is supported by evidence-based symptom control.
Palliative medicine specialists, through their unique multiple experiences as engaged clinicians, recognise dying and do not view death as a failure, unlike much of the rest of medicine. This aspect is an important component of any CODp. Such recognition and acceptance allows for truthful, realistic and timely end-of-life discussions with patients and their caregivers or families.
Chan and Webster 2 understand the pathway as a single clinical intervention, rather than a framework that guides the clinician. The danger of applying a reductionist approach, thereby subjecting a quality framework of care for a population of patients (terminal phase) to the rigors of pure randomized control clinical trial research, reduces the individual care of a dying person to ‘a one size fits all’ approach. No two “pathways” look the same on scrutiny, just as no two patients make the same “journey into the night.”
As such the argument in the letter by Chan and Webster 2 raises issues profound around the best research methodology to use for investigating the impact of complex multidisciplinary care plans, and the impact of health system changes brought about by care pathways for improving the care of the dying.
The limitations of randomized controlled trials as a research methodology are made more obvious when we try to use them to investigate questions around: quality of care provision, health systems design changes, and their impact on evidence. Currently there is debate raging within the Cochrane Collaboration itself with the development of the qualitative methods research group and the effective practice and organization of care subgroups.
There was unanimous agreement at the aforementioned ANZSPM workshop that there was no evidence of harm with the use of a pathway. 1 If the CODp was a prescribed medication (thus applying a “one size fits all”-reductionist approach) the number needed to harm (NNH) would imply low level of risk to the prescriber.
Importantly the ANZSPM Clinical Indicators Working Group was able to determine that there was consensus through expert opinion that the use of a CODp provides current best practice care of the dying. The ANZSPM Clinical Indicators Working Group are progressing the development of the care of the dying CI.
We in the Antipodes are grateful that compassionate and rational care can be afforded to the dying.