This systematic evidence review supports the American College of Physicians guideline on palliative care at the end of life. Strong to moderate evidence supports use of various treatments for cance...

Evidence for Improving Palliative Care at the End of Life: A Systematic Review

Background: Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. Objective: Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. Methods: Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). Setting and sample: Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. Measures: Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. Results: IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p...

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Impact of an inpatient palliative care team: a randomized control trial.

Background
Extensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world.

Objectives
1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness.

Search methods
We searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data.

Selection criteria
We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both.

Data collection and analysis
One review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home).

Main results
We identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS and multiple sclerosis (MS), among other conditions. Meta-analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi2 = 20.57, degrees of freedom (df) = 6, P value = 0.002; I2 = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost-effectiveness (six studies) is inconclusive.

Authors' conclusions
The results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost-effectiveness especially for people with non-malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies.

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Effectiveness and cost‐effectiveness of home palliative care services for adults with advanced illness and their caregivers

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Context Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality. Objective To systematically review the evidence for effectiveness of specialized palliative care. Data Sources We performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials. Study Selection We included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost. Data Extraction Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria. Results Of 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence. Conclusions The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.

Effectiveness of Specialized Palliative Care: A Systematic Review

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care or conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on o...

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review.

This systematic literature review examined the impact of specialist models of palliative care on consumer satisfaction, opinion and preference over the past 20 years. From the literature search, 83 relevant papers were identified. Research findings from North America did not reveal any reliable or consistent trends, and this was due primarily to methodological flaws in the research. In the UK, consumers are more satisfied with all types of palliative care, whether provided by inpatient units or in the community, than with palliative care provided by general hospitals. Even though research findings consistently indicate that consumers appreciate the psychosocial climate in hospices, this research was based on small-scale local studies which were mainly focused on a single hospice. The dearth of high quality, comprehensive research was notable on the impact on consumer preference, opinion or satisfaction of hospice home care services, and other forms of palliative care in the community. It was concluded that further research is needed into consumer priorities for patients dying of noncancer diseases, and into the possible impact of patient characteristics on consumer satisfaction, opinion and preference for specialist models of palliative care.

Patient and carer preference for, and satisfaction with, specialist models of palliative care: a systematic literature review.

An increased emphasis on quality assurance in the National Health Service (NHS) became evident in the literature related to health following the Government's White Paper, "Working for Patients" (1989) and the Patients' Charter (1991). The latter included specific quality standards to which purchasers and providers of health care made a commitment. This review of published and un-published (grey) literature concentrates on patient views about outpatient services in British hospitals, with special emphasis on the role of nurses. Findings indicate central emphasis on easily measurable factors, such as waiting times in outpatient departments and comparative neglect of more qualitative aspects, which may be of greater importance to patients. Specific attention has been given to exploring the role of nurses working in the outpatient department, which appears to be under-researched, based on this selective literature review.

Listening to patients in the National Health Service: a selective review of literature on patients' views about outpatient services in British hospitals

M Lorentzon

Papers

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review.

Patient and carer preference for, and satisfaction with, specialist models of palliative care: a systematic literature review.

Listening to patients in the National Health Service: a selective review of literature on patients' views about outpatient services in British hospitals