The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What Circumstances?

Dalkin, Sonia (2014) The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What Circumstances? Doctoral thesis, Northumbria University.

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Abstract

Background: Finding effective ways to care for people with palliative care needs is a national priority. A primary care locality has developed and implemented an Integrated Care Pathway (ICP) for those with life limiting illnesses. It focuses on identifying patients early, regardless of disease type, and uses proactive and patient centred interventions to plan for a good death. Although palliative care pathways present a promising practice framework, the literature does not allow for an assessment of how and when they work best. This thesis aimed to explain which parts of the ICP worked best, for whom and in what circumstances.

Design: Realist evaluation was used to guide the analysis of multiple data strands: quantitative data from the GP practices; interviews with palliative care patients and bereaved relatives; bereaved relatives and matched health care professional questionnaires; focus groups with health care professionals; consultation recordings with palliative care patients and their GPs.

Results: The results of this study are multifaceted, and focus on the conditions of successful implementation, such as the presence of a champion; palliative care registration decisions for all diagnoses and the importance of leadership and peer support; advance care planning, including the roles of mental capacity and time constraints; communication in consultations and the role of patient and GP traits; and using open multicomponent communication strategies to facilitate home deaths.

Discussion: A realist approach has exposed how the ICP implementation has led to positive practice and patient level outcomes. The ICP can be construed as a translational tool, which enables the operationalisation of policy directives on shared decision making, proactivity and patient centeredness in primary care. In the context of palliative care, this study allows important reconceptualisations of shared decision making and advance care planning to be presented.

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