Implementation of knowledge-based palliative care in acute care settings : obstacles, opportunities and experiences

Background and aim: Quality improvement is continuously ongoing at different levels in our healthcare system. In Sweden, as in other countries, guidelines are important for quality improvement in healthcare, since they summarize the best available evidence. Improved living conditions and enhanced treatments for a variety of diseases have resulted in increased longevity and the need for palliative care has therefore also increased. A high proportion of deaths occur in acute care settings, where the care has been described as inadequate for dying patients. In 2013, the National Board of Health and Welfare published A National knowledgebased guidance for good palliative care in end-of-life care and just prior to this in 2012, the Regional Cancer Centre published the National clinical practice guideline for palliative care. The overarching aim of this thesis was to study implementation of knowledge-based palliative care in acute care settings. Methods and results of the studies: The first and second studies covered aspects that were to be taken into account for the implementation of the documents described above. In study I, national policy documents in Sweden were reviewed for quality indicators relevant to palliative care and end-of-life care. In study II, perceptions regarding national palliative care guidelines were investigated and obstacles to and opportunities for implementing these guidelines in acute care hospitals were identified through interviews with local politicians, chief medical officers and healthcare professionals. The results showed scarce knowledge of the two documents at all levels of the healthcare organisation. Palliative care was primarily described as end-of- life care. The environment and culture in hospitals, with heavy workload, poor communication and poor teamwork, were described as obstacles for implementation. However, staff emphasised a need for training and support in palliative care through theoretical knowledge and mentoring to develop clinical skills. An implementation strategy for the use of the Integrated Palliative care Outcome Scale (IPOS) was developed. The strategy included information, training and facilitation to support the use of the scale. The implementation was performed at three acute care settings and, to gain a broader understanding of the strategy, it was also tested at a palliative care unit. The evaluation of the strategy, presented in study III and IV, was conducted through multiple methods. The findings showed varying prevalence of completed IPOS, indicating shortcomings in implementation. Conclusion: The awareness of the two documents on palliative care varied at all levels in the healthcare organisation, being predominantly low among healthcare professionals in acute care settings. The feasibility of the performed implementation strategy was considered questionable and the components need to be further explored to enhance the impact of implementation and thereby improve the use of IPOS in acute care settings