Evaluation of a Palliative Care Program for Nursing Homes in 7 Countries: The PACE Cluster-Randomized Clinical Trial | Geriatrics | JAMA Internal Medicine | JAMA Network
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    Original Investigation
    November 11, 2019

    Evaluation of a Palliative Care Program for Nursing Homes in 7 Countries: The PACE Cluster-Randomized Clinical Trial

    Author Affiliations
    • 1VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium
    • 2Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussel, Belgium
    • 3Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
    • 4Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
    • 5Amsterdam Public Health Research Institute, Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
    • 6Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
    • 7Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
    • 8IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
    • 9International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
    • 10Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
    • 11National Institute for Health and Welfare, Helsinki, Finland
    • 12Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
    • 13Università Cattolica del Sacro Cuore, Rome, Italy
    • 14Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
    • 15Center for the Interdisciplinary Study of Gerontology and Vulnerability (CIGEV), University of Geneva, Geneva, Switzerland
    • 16Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Belgium
    • 17Department of Public Health and Primary Care, Ghent University, Belgium
    JAMA Intern Med. 2020;180(2):233-242. doi:10.1001/jamainternmed.2019.5349
    Key Points

    Question  Is the Palliative Care for Older People (PACE) Steps to Success Program, a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes, effective in improving resident and staff outcomes?

    Findings  In a cluster-randomized clinical trial in 78 nursing homes in 7 countries evaluating data concerning 551 deceased residents at baseline and 984 postintervention, and data concerning 2680 staff at baseline and 2437 postintervention, comparing PACE Steps to Success with usual care, residents’ comfort in the last week of life did not improve. Staff knowledge of palliative care improved, but the difference was very small.

    Meaning  The PACE Steps to Success Program was not effective in improving residents’ comfort in the last week of life, nor in improving staff knowledge of palliative care to a clinically relevant degree.


    Importance  High-quality evidence on how to improve palliative care in nursing homes is lacking.

    Objective  To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes.

    Design, Setting, and Participants  A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio.

    Interventions  The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death.

    Main Outcomes and Measures  The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1).

    Results  Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents’ comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, −0.55; 95% CI, −1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018.

    Conclusions and Relevance  Residents’ comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important.

    Trial Registration  ISRCTN Identifier: ISRCTN14741671