title: Systematic realist review of key factors affecting the successful implementation and sustainability of the Liverpool care pathway for the dying patient.
abstract: BACKGROUND
  The Liverpool Care Pathway (LCP) is recommended internationally as a best practice model for the care of patients and their families at the end of life. However, a recent national audit in the United Kingdom highlighted shortcomings; and understanding is lacking regarding the processes and contextual factors that affect implementation.
  
  
  OBJECTIVE
  To identify and investigate factors that help or hinder successful implementation and sustainability of the LCP.
  
  
  METHODS
  Electronic databases (Medline, CINAHL, British Nursing Index, Science Direct) and grey literature were searched, supplemented by citation tracking, in order to identify English language papers containing information relevant to the implementation of the LCP. Using a realist review approach, we systematically reviewed all relevant studies that focused on end of life care and integrated care pathway processes and identified theories that explained how the LCP and related programmes worked.
  
  
  RESULTS
  Fifty-eight papers were included in the review. Key factors identified were: a dedicated facilitator, education and training, audit and feedback, organisational culture, and adequate resources.
  
  
  CONCLUSIONS
  We discuss how these factors change behaviour by influencing the beliefs, attitudes, motivation and confidence of staff in relation to end of life care, and how contextual factors moderate behaviour change.
  
  
  CONCLUSIONS
  The implementation process recommended by the developers of the LCP is necessary but not sufficient to ensure successful implementation and sustainability of the pathway. The key components of the intervention (a dedicated facilitator, education and training, audit and feedback) must be configured to influence the beliefs of staff in relation to end of life care, and increase their motivation and self-efficacy in relation to using the LCP. The support of senior managers is vital to the release of necessary resources, and a dominant culture of cure, which sees every death as a failure, works against effective communication and collaboration in relation to the LCP.
authors.affiliation: Doctoral student, School of Nursing and Midwifery, Queen's University of Belfast, Belfast, Northern Ireland.
authors.forename: Tracey
authors.initials: T
authors.lastname: McConnell
authors.forename: Peter
authors.initials: P
authors.lastname: O'Halloran
authors.forename: Sam
authors.initials: S
authors.lastname: Porter
authors.forename: Michael
authors.initials: M
authors.lastname: Donnelly
mesh_terms: D019091:Critical Pathways / Q000458:organization & administration*; D055317:Evidence-Based Practice; D064946:Hospice and Palliative Care Nursing / Q000379:methods / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D010166:Palliative Care / Q000379:methods / Q000458:organization & administration*; D013727:Terminal Care / Q000379:methods / Q000458:organization & administration*
keywords: Liverpool Care Pathway; end of life; implementation; palliative care; realist review