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The Cochrane Database of Systematic... Sep 2020Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously.
OBJECTIVES
To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families.
SEARCH METHODS
We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available.
MAIN RESULTS
We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision.
AUTHORS' CONCLUSIONS
Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.
Topics: Ambulatory Care; Bias; Caregivers; Cost-Benefit Analysis; Family; Heart Failure; Home Care Services, Hospital-Based; Hospitalization; Humans; Neoplasms; Pain Management; Palliative Care; Patient Satisfaction; Quality of Life; Randomized Controlled Trials as Topic; Symptom Assessment; Terminal Care
PubMed: 32996586
DOI: 10.1002/14651858.CD012780.pub2 -
Palliative Medicine Feb 2019Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient... (Meta-Analysis)
Meta-Analysis
BACKGROUND:
Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient and caregiver outcomes are not well-understood.
AIM:
We evaluated the effects of integrated outpatient palliative and oncology care for advanced cancer on patient and caregiver outcomes.
DESIGN:
Following a standard protocol (PROSPERO: CRD42017057541), investigators independently screened reports to identify randomized controlled trials or quasi-experimental studies that evaluated the effect of integrated outpatient palliative and oncology care interventions on quality of life, survival, and healthcare utilization among adults with advanced cancer. Data were synthesized using random-effects meta-analyses, supplemented with qualitative methods when necessary.
DATA SOURCES:
English-language peer-reviewed publications in PubMed, CINAHL, and Cochrane Central through November 2016. We subsequently updated our PubMed search through July 2018.
RESULTS:
Eight randomized-controlled and two cluster-randomized trials were included. Most patients had multiple advanced cancers, with median time from diagnosis or recurrence to enrollment ranging from 8 to 12 weeks. All interventions included a multidisciplinary team, were classified as “moderately integrated,” and addressed physical and psychological symptoms. In a meta-analysis, short-term quality of life improved, symptom burden improved, and all-cause mortality decreased. Qualitative analyses revealed no association between integration elements, palliative care intervention elements, and intervention impact. Utilization and caregiver outcomes were often not reported.
CONCLUSIONS:
Moderately integrated palliative and oncology outpatient interventions had positive effects on short-term quality of life, symptom burden, and survival. Evidence for effects on healthcare utilization and caregiver outcomes remains sparse.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Care; Delivery of Health Care, Integrated; Female; Hospice and Palliative Care Nursing; Humans; Male; Middle Aged; Neoplasms; Palliative Care; Practice Guidelines as Topic; Terminal Care
PubMed: 30488781
DOI: 10.1177/0269216318812633 -
Annals of Palliative Medicine Feb 2019Palliative care offers patients with a serious illness and their families access to services that can improve quality of life, mood, and symptoms. However, the term... (Meta-Analysis)
Meta-Analysis
Palliative care offers patients with a serious illness and their families access to services that can improve quality of life, mood, and symptoms. However, the term palliative care is often confused with end of life or hospice services limiting its application to persons with chronic illnesses who might benefit. Non-hospice palliative care is a term that is emerging to more accurately reflect the broader care model that palliative care represents. The aim of this review was to identify the characteristics of published nonhospice palliative care interventions. We derived our sample predominantly from a recently published systematic review and meta-analysis and selected studies published since the review. Inclusion criteria were: self-described palliative care intervention studies using randomized designs for participants with lifelimiting illnesses aged 18 years or older. These 38 studies fell into 3 broad categories: primary, specialty, and hybrid models. Common challenges among these models include limited education of generalists, limited reimbursement, and limited access in certain areas. However, increasing palliative care usage has also been associated with increased hospice use and appropriate timing of referrals.
Topics: Adolescent; Adult; Aged; Ambulatory Care; Facilities and Services Utilization; Home Care Services; Hospice Care; Hospitalization; Humans; Middle Aged; Models, Organizational; Palliative Care; Patient Care Team; Randomized Controlled Trials as Topic; Young Adult
PubMed: 29860852
DOI: 10.21037/apm.2018.03.11 -
The Benefits and Burdens of Pediatric Palliative Care and End-of-Life Research: A Systematic Review.Journal of Palliative Medicine Aug 2019The aim of this study is to report the benefits and burdens of palliative research participation on children, siblings, parents, clinicians, and researchers. Pediatric...
The aim of this study is to report the benefits and burdens of palliative research participation on children, siblings, parents, clinicians, and researchers. Pediatric palliative care requires research to mature the science and improve interventions. A tension exists between the desire to enhance palliative and end-of-life care for children and their families and the need to protect these potentially vulnerable populations from untoward burdens. Systematic review followed PRISMA guidelines with prepared protocol registered as PROSPERO #CRD42018087304. MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and The Cochrane Library were searched (2000-2017). English-language studies depicting the benefits or burdens of palliative care or end-of-life research participation on either pediatric patients and/or their family members, clinicians, or study teams were eligible for inclusion. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Twenty-four studies met final inclusion criteria. The benefit or burden of palliative care research participation was reported for the child in 6 papers; siblings in 2; parents in 19; clinicians in 3; and researchers in 5 papers. Benefits were more heavily emphasized by patients and family members, whereas burdens were more prominently emphasized by researchers and clinicians. No paper utilized a validated benefit/burden scale. The lack of published exploration into the benefits and burdens of those asked to take part in pediatric palliative care research and those conducting the research is striking. There is a need for implementation of a validated benefit/burden instrument or interview measure as part of pediatric palliative and end-of-life research design and reporting.
Topics: Adolescent; Adult; Attitude of Health Personnel; Biomedical Research; Child; Child, Preschool; Family; Female; Health Personnel; Humans; Infant; Infant, Newborn; Male; Palliative Care; Pediatrics; Professional-Family Relations; Qualitative Research; Terminal Care
PubMed: 30835596
DOI: 10.1089/jpm.2018.0483 -
Journal of Palliative Medicine May 2021Depression can be quite common in the palliative care population. The estimated prevalence ranges from 24% to 70%. Depression in this population leads to a decreased...
Depression can be quite common in the palliative care population. The estimated prevalence ranges from 24% to 70%. Depression in this population leads to a decreased quality of life and may lead to a desire for an earlier death. We conducted a systematic review to establish a better understanding of the available treatment interventions, both pharmacological and nonpharmacological specific to the palliative population. PubMed, PsycINFO, and CINAHL databases were searched using the MeSH terms: Palliative Care, Palliative Medicine, Terminal Illness, End of Life Care, and Depression or Depressive Disorder, as well as the keywords palliative care, care palliative, and depression. We considered all published peer-reviewed articles written in English and pertaining to humans. Articles were hand searched from citations. The Mixed Methods Appraisal Tool was used for study quality appraisal. Thirty-nine eligible articles were found; 29 articles examined nonpharmacological options, while 10 focused on pharmacological options. The 29 articles discussing nonpharmacological methods discussed 22 interventions. Of the 22 interventions, 10 showed therapeutic benefit. Of the 10 studies focusing on pharmacological interventions, seven showed therapeutic benefit. This is the first systematic review that examined both nonpharmacological and pharmacological methods to treat depression in the palliative setting. There is evidence to indicate that methylphenidate and antidepressants can provide a therapeutic benefit for palliative care patients with depressive symptoms. This benefit may be enhanced when these medications are used in combination. The use of music therapy or future-focused psychotherapy may also be beneficial in the treatment of depression.
Topics: Depression; Hospice and Palliative Care Nursing; Humans; Music Therapy; Palliative Care; Quality of Life
PubMed: 33720758
DOI: 10.1089/jpm.2020.0659 -
The American Journal of Hospice &... Aug 2018To present the findings of a systematic review on the use of simulation-based learning experiences (SBLEs) to teach communication skills to nursing students and... (Review)
Review
OBJECTIVES
To present the findings of a systematic review on the use of simulation-based learning experiences (SBLEs) to teach communication skills to nursing students and clinicians who provide palliative and end-of-life care to patients and their families.
BACKGROUND
Palliative care communication skills are fundamental to providing holistic patient care. Since nurses have the greatest amount of direct exposure to patients, building such communication competencies is essential. However, exposure to patients and families receiving palliative and end-of-life care is often limited, resulting in few opportunities to learn these skills in the clinical setting. Simulation-based learning experiences can be used to supplement didactic teaching and clinical experiences to build the requisite communication skills.
METHODS
Searches of CINAHL, MEDLINE, PsychINFO, ERIC, and Web of Science electronic databases and Grey Literature returned 442 unique records. Thirty articles met the established criteria, including the SBLE must contain a nursing role.
RESULTS
Simulation-based learning experience are being used to teach palliative and end-of-life communication skills to nursing students and clinicians. Lack of standardization, poor evaluation methods, and limited exposure to the entire interprofessional team makes it difficult to identify and disseminate validated best practices.
CONCLUSION
While the need for further research is acknowledged, we recommend this evidence be augmented by training programs that utilize SBLEs through (1) applying standards, (2) clearly specifying goals and objectives, (3) integrating externally validated scenarios, and (4) employing rigorous evaluation methods and measures that link the SBLE to the training objectives and desired clinician practice behaviors and patient outcomes.
Topics: Clinical Competence; Communication; Education, Nursing; Formative Feedback; Humans; Nurse's Role; Palliative Care; Simulation Training; Terminal Care
PubMed: 29514480
DOI: 10.1177/1049909118761386 -
BMC Oral Health Mar 2020High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to...
BACKGROUND
High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to communicate their sufferings. Therefore, it may lead to under-reporting of oral conditions among these patients. This review systematically synthesized the published evidence on the presence of oral conditions among palliative patients, the impact, management, and challenges in treating these conditions.
METHODS
An integrative review was undertaken with defined search strategy from five databases and manual search through key journals and reference list. Studies which focused on oral conditions of palliative patients and published between years 2000 to 2017 were included.
RESULTS
Xerostomia, oral candidiasis and dysphagia were the three most common oral conditions among palliative patients, followed by mucositis, orofacial pain, taste change and ulceration. We also found social and functional impact of having certain oral conditions among these patients. In terms of management, complementary therapies such as acupuncture has been used but not well explored. The lack of knowledge among healthcare providers also posed as a challenge in treating oral conditions among palliative patients.
CONCLUSIONS
This review is first in its kind to systematically synthesize the published evidence regarding the impact, management and challenges in managing oral conditions among palliative patients. Although there is still lack of study investigating palliative oral care among specific group of patients such as patients with dementia, geriatric or pediatric advanced cancer patients, this review has however provided baseline knowledge that may guide health care professionals in palliative settings.
Topics: Aged; Child; Humans; Mouth Diseases; Oral Health; Oral Ulcer; Palliative Care; Terminally Ill; Xerostomia
PubMed: 32188452
DOI: 10.1186/s12903-020-01075-w -
BMJ (Clinical Research Ed.) Jul 2017To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness. Systematic review... (Meta-Analysis)
Meta-Analysis Review
Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis.
To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness. Systematic review with meta-analysis. Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and trial registers searched up to July 2016. Randomised controlled trials with adult inpatients or outpatients treated in hospital, hospice, or community settings with any advanced illness. Minimum requirements for specialist palliative care included the multiprofessional team approach. Two reviewers independently screened and extracted data, assessed the risk of bias (Cochrane risk of bias tool), and evaluated the quality of evidence (GRADE tool). Primary outcome was quality of life with Hedges' g as standardised mean difference (SMD) and random effects model in meta-analysis. In addition, the pooled SMDs of the analyses of quality of life were re-expressed on the global health/QoL scale (item 29 and 30, respectively) of the European Organization for Research and Treatment of Cancer QLQ-C30 (0-100, high values=good quality of life, minimal clinically important difference 8.1). Of 3967 publications, 12 were included (10 randomised controlled trials with 2454 patients randomised, of whom 72% (n=1766) had cancer). In no trial was integration of specialist palliative care triggered according to patients' needs as identified by screening. Overall, there was a small effect in favour of specialist palliative care (SMD 0.16, 95% confidence interval 0.01 to 0.31; QLQ-C30 global health/QoL 4.1, 0.3 to 8.2; n=1218, six trials). Sensitivity analysis showed an SMD of 0.57 (-0.02 to 1.15; global health/QoL 14.6, -0.5 to 29.4; n=1385, seven trials). The effect was marginally larger for patients with cancer (0.20, 0.01 to 0.38; global health/QoL 5.1, 0.3 to 9.7; n=828, five trials) and especially for those who received specialist palliative care early (0.33, 0.05 to 0.61, global health/QoL 8.5, 1.3 to 15.6; n=388, two trials). The results for pain and other secondary outcomes were inconclusive. Some methodological problems (such as lack of blinding) reduced the strength of the evidence. Specialist palliative care was associated with a small effect on QoL and might have most pronounced effects for patients with cancer who received such care early. It could be most effective if it is provided early and if it identifies though screening those patients with unmet needs. PROSPERO CRD42015020674.
Topics: Adult; Caregivers; Decision Making; Hospices; Humans; Outcome Assessment, Health Care; Palliative Care; Quality of Life; Randomized Controlled Trials as Topic; Terminally Ill
PubMed: 28676557
DOI: 10.1136/bmj.j2925 -
JBI Database of Systematic Reviews and... Jun 2015Cancer care nursing is perceived as personally and professionally demanding. Developing effective coping skills and resilience has been associated with better health and... (Review)
Review
BACKGROUND
Cancer care nursing is perceived as personally and professionally demanding. Developing effective coping skills and resilience has been associated with better health and wellbeing for nurses, work longevity and improved quality of patient care.
OBJECTIVES
The objective of this systematic review was to identify personal and organizational strategies that promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy.
METHODS
The search strategy identified published and unpublished studies from 2007 to 2013. Individual search strategies were developed for the 12 databases accessed and search alerts established. The review considered qualitative, quantitative and mixed methods studies that assessed personal or organizational interventions, programs or strategies that promoted coping and resilience. These included studies employing clinical supervision, staff retreats, psycho-educational programs, compassion fatigue resilience programs, stress inoculation therapy and individual approaches that reduced the emotional impact of cancer care work. The outcomes of interest were the experience of factors that influence an individual's coping and resilience and outcomes of validated measures of coping or resilience. Methodological quality of studies was independently assessed by two reviewers prior to inclusion in the review using standardized critical appraisal instruments developed by the Joanna Briggs Institute. Standardized Joanna Briggs Institute tools were also used to extract data. Agreement on the synthesis of the findings from qualitative studies was reached through discussion. The results of quantitative studies could not be statistically pooled given the different study designs, interventions and outcome measures. These studies were presented in narrative form.
RESULTS
Twenty studies were included in the review. Ten studies examined the experience of nurse's caring for the dying, the emotional impact of palliative care and oncology work and strategies to prevent burnout or avoid compassion fatigue, challenges in self-care, and processes nurses adopted to cope with work related stress. Six studies evaluated different interventions provided by organizations to improve coping and resilience. Evidence for the effectiveness of interventions was limited to three studies. The results are discussed under four headings: (i) preventative measures (ii) control measures (iii) unburdening and "letting go", and (iv) growing and thriving.
CONCLUSION
This review identified a number of strategies to better prepare nurses for practice and maintain their psychological wellbeing. Although no firm conclusions can be drawn in respect to the most effective interventions, strategies with merit included those that: a) foster connections within the team; b) provide education and training to develop behaviors that assist in controlling or limiting the intensity of stress, or aiding recovery; and c) assist in processing emotion and learning from experiences. Although individuals must take responsibility for developing personal strategies to assist coping and resilience, organizational support is integral to equipping individuals to deal with work related challenges.
IMPLICATIONS FOR PRACTICE
A range of formal and informal support is required to promote coping and resilience.
IMPLICATIONS FOR RESEARCH
There is a need for large, well designed, multisite, experimental studies to evaluate the effectiveness of interventions that promote coping and resilience in adult palliative care or oncology nurses.
Topics: Adaptation, Psychological; Adult; Burnout, Professional; Female; Humans; Inservice Training; Neoplasms; Nursing Staff, Hospital; Oncology Nursing; Palliative Care; Qualitative Research; Resilience, Psychological; Self Care
PubMed: 26455609
DOI: 10.11124/jbisrir-2015-1898 -
Palliative Medicine Jun 2019Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative...
BACKGROUND
Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase.
AIM
To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective.
DESIGN
Systematic review (PROSPERO no. 95581) with meta-aggregation method.
DATA SOURCES
Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied.
RESULTS
In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care.
CONCLUSION
The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.
Topics: Adult; Aged; Aged, 80 and over; Attitude to Death; Caregivers; Family; Female; Hospice Care; Humans; Male; Middle Aged; Nursing Homes; Palliative Care; Qualitative Research; Terminal Care
PubMed: 30969160
DOI: 10.1177/0269216319840275