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Randomized Controlled Trial
, 17 (1), 47

Integrating Palliative Care in Long-Term Care Facilities Across Europe (PACE): Protocol of a Cluster Randomized Controlled Trial of the 'PACE Steps to Success' Intervention in Seven Countries

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Randomized Controlled Trial

Integrating Palliative Care in Long-Term Care Facilities Across Europe (PACE): Protocol of a Cluster Randomized Controlled Trial of the 'PACE Steps to Success' Intervention in Seven Countries

Tinne Smets et al. BMC Palliat Care.


Background: Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the 'PACE Steps to Success' palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries.

Methods: We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the 'Pace Steps to Success intervention' or to 'care as usual'. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey).

Secondary outcomes: resident's quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework.

Discussion: The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities 'PACE Steps to Success' in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems.

Trial registration: The study is registered at - ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015.

Keywords: Care home; End-of-life care; Nursing home; Palliative care; Quality improvement.

Conflict of interest statement

Ethics approval and consent to participate

Ethics approval from the relevant ethics committees were obtained in all participating countries.

Belgium: Commissie Medische Ethiek UZBrussel, 27/05/2015; England: NHS – NRES Committee North West-Haydock, 10/09/2015; Finland: Terveyden jahyvinvoinnin laitos, Institutet för hälsa och välfärd, 30/6/2015; Italy: Comitato Etico, Universita Cattolica del Sacro Cuore, 6/11/2017; Netherlands: Medisch Ethische Toetsingscommissie VUMedisch Centrum, 2/7/2015; Poland: Komisja Bioetycza, Uniwersytetu Jagiellonskiego, 25/6/2015; Switzerland: Commission cantonale d’éthique de la recherché scientifique de Genève (CCER), 6/8/2015.

All persons participating in the study (facility managers, care staff, GPs, relatives, and the concerned residents and relatives in the interviews for the process evaluation) have to give their prior informed consent in writing. If residents are unable to give informed consent, they will not be involved in the study. In some countries, such as Poland and the Netherlands, a separate informed consent is not required if questionnaires are filled in anonymously.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Fig. 1
Fig. 1
Flowchart of the cluster randomised controlled trial
Fig. 2
Fig. 2
12-month implementation of PACE Steps to Success

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