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Implementing an Integrated Palliative Care Pathway in Long-Term Care Facilities
Maria Elisa Finelli1, Francesco Romagnoli2, Samuele Benatti3
1Palliative Care Unit, Azienda Unità Sanitaria Locale (AUSL) di Modena, Modena, Italy.
Journal of Pain and Symptom Management
|August 11, 2026
Summary
Implementing a palliative care pathway in long-term care facilities (LTCFs) improved end-of-life care. This pathway facilitated timely identification and integration of palliative care needs for frail residents, reducing hospitalizations.
Area of Science:
- Gerontology
- Palliative Care
- Healthcare Management
Background:
- Long-term care facilities (LTCFs) often face challenges in recognizing and addressing the palliative care needs of residents with complex conditions like frailty and dementia.
- Late identification of palliative care needs can lead to suboptimal end-of-life experiences for residents.
Purpose of the Study:
- To evaluate the feasibility and impact of a newly developed palliative care pathway in LTCFs.
- To improve the identification and integration of palliative care services within the Local Palliative Care Network.
Main Methods:
- A pathway (Procedure DS.DO.171) was implemented using tools like the surprise question and SPICT (Supportive and Palliative Care Indicators Tool) for needs assessment.
- Multidisciplinary reviews, goals-of-care discussions, and referrals to the Home Palliative Care Unit were integral components.
- Baseline and post-implementation data were collected from LTCFs, including palliative care needs, care plans, place of death, and hospitalizations.
Main Results:
- The study enrolled 405 residents (mean age 87.1 years, 70.9% female) from April to December 2024.
- The vast majority of deaths (98.0%) occurred within LTCFs, indicating successful end-of-life care localization.
- Hospitalizations significantly decreased from a mean of 0.96 to 0.04 after referral to the palliative care pathway.
Conclusions:
- An organization-wide palliative care pathway in LTCFs is a feasible model for enhancing end-of-life care.
- The pathway demonstrated potential in supporting residents' palliative care needs and reducing hospital transfers.
- Further research is needed to cautiously interpret these promising findings.
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