Arrangements for care will vary according to where the dying person is being cared for. Practicalities can be very different in rural or remote areas compared with an urban environment.  Clinicians need to adapt their practice to the realities of the care that is able to be provided, and to the skill and coping abilities of the caregivers.  This is true whether the person is dying at home, in a nursing home, or in an acute care setting.
Within the healthcare system the culture of care differs in different settings. For instance, healthcare teams in an intensive care unit or an emergency department may have different perceptions of the issues of comfort, and the role of the family, from those of staff in residential aged care, or a surgical unit, and in a palliative care unit or an oncology ward.  These differences can have a significant impact on patients’ and families’ experiences of end-of-life care.
End-of-life care pathways are clinical pathways that were initially developed in the UK and more recently are being used in other countries including Australia. They are intended to guide the care of dying patients in different settings of care. 
End-of-life care pathways are based on a “gold standard” of end-of-life care as developed in the hospice setting. However, whilst the key goals form a common core of all end-of-life care pathways, specific prescribing guidance is largely derived from expert opinion, and often reflects variations in local practices. The evidence base to support specific prescribing recommendations is often not strong. 
What is known
- Despite the widespread implementation of end-of-life care pathways, a recent Cochrane review could not identify any well designed controlled studies that assessed the effects of these pathways on care for the dying.  However there is supportive evidence from audits and implementation studies in different health care settings. [7-11]
- A systematic review identified a lack of research about death in nursing homes, despite the fact that it is a common site for end-of-life care to be given. The studies which were included found there were problems in identification of the patients requiring end-of-life care, lack of symptom control and high prevalence of poorly controlled pain, and improvements in care when palliative care providers were involved in care in the nursing home setting. Their involvement led to improvements in pain control, increased numbers of residents having advance care plans, and decreased numbers of hospitalisations at the end of life. 
- End-of-life care and decision-making are frequent issues for critically ill patients in intensive care units.  Issues identified in the literature suggest that, as in other healthcare settings, communication and processes of decision-making are the main concerns of families, as well as adequacy of pain management during the dying process.  Consensus guidelines are evolving regarding the best practice in caring for dying patients in the ICU environment. 
- Having inadequate family support and / or community-based palliative care services is often, in practice, a limiting factor for patients who wish to die at home. [16-17] However planning ahead and good teamwork may help prevent unwanted hospitalisation when a dying person wants to stay at home. 
What it means in practice
- Planning the end-of-life care for a dying patient may also require an assessment of the setting in which the person is being cared for, and of the capacity and needs of the caregivers.
- Caregivers, including the family, need to understand the plan of care, and be able to contribute to decision-making and ongoing assessment of the patient. Good teamwork, good documentation, and good communication are essential.
- Strategies that focus on education and culture change, and developing appropriate quality measures, should be individualised to the setting of care. Nonetheless, key principles of end-of-life care remain the same in all settings.
- The Gold Standards Framework (UK), is a model which promotes palliative care provision in the primary care / general practice setting, and has been shown to improve processes of care for patients in the community, although it needs to be further evaluated with regard to direct outcomes for patients and caregivers.