 |
 |
|
15 January 2008 | Volume 148 Issue 2 | Pages 147-159
Background: Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care.
Purpose: To assess evidence about interventions to improve palliative and end-of-life care.
Data Sources: English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance.
Study Selection: Systematic reviews that addressed "end of life," including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving.
Data Extraction: Single reviewers screened 24 423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification.
Data Synthesis: Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure.
Limitations: Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis.
Conclusion: Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.
Author and Article Information
From Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Southern California Evidence-based Practice Center and RAND Health, Santa Monica, California; Johns Hopkins University, Baltimore, Maryland; Agency for Healthcare Research and Quality, Bethesda, Maryland; City of Hope, Duarte, California; and Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
Disclaimer: The views expressed herein do not represent the views of the U.S. Department of Veterans Affairs, Agency for Healthcare Research and Quality (AHRQ), or National Institute of Nursing Research.
Grant Support: The National Institute of Nursing Research and the Agency for Healthcare Research and Quality (grant no. 290-02-0003) provided funding for this project. Dr. Lorenz was supported by a Veterans Affairs Health Services Research & Development Service Career Development Award, and Dr. Dy was supported by a K07 award from the National Cancer Institute (K07-CA096 783).
Potential Financial Conflicts of Interest: Grants received: K.A. Lorenz (Amgen).
Requests for Single Reprints: Karl A. Lorenz, MD, MSHS, Division of General Internal Medicine, Veterans Integrated Palliative Program, Veterans Affairs Greater Los Angeles Healthcare System, 11031 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073; e-mail, karl.lorenz{at}med.va.gov.
Current Author Addresses: Drs. Lorenz and Shekelle: Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073.
Dr. Lynn: Center for Medicare & Medicaid Services, Office of Standards and Quality, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850.
Dr. Dy: Johns Hopkins Bloomberg School of Public Health, Room 609, 624 North Broadway, Baltimore, MD 21205.
Drs. Shugarman and Maglione, Ms. Hilton, Ms. Rhodes, Ms. Rolon, and Ms. Sun: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208.
Dr. Wilkinson: Western Australia Center for Cancer and Palliative Care, Edith Cowan University, Building 19, Churchlands Campus, Pearson Street, Churchlands, WA 6018, Australia.
Dr. Mularski: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate, WIN 1060, Portland, OR 97227.
Dr. Morton: Research Triangle Institute, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.
Dr. Hughes: Agency for Healthcare Research and Quality, John M. Eisenberg Building, 540 Gaither Road, Rockville, MD 20850. CLINICAL GUIDELINES
Evidence for Improving Palliative Care at the End of Life: A Systematic Review
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  G Grande, K Stajduhar, S Aoun, C Toye, L Funk, J Addington-Hall, S Payne, and C Todd Supporting lay carers in end of life care: current gaps and future priorities Palliative Medicine, June 1, 2009; 23(4): 339 - 344. [Abstract] [PDF]
|
|
|
|
 |
|
 T. Jaarsma, J. M. Beattie, M. Ryder, F. H. Rutten, T. McDonagh, P. Mohacsi, S. A. Murray, T. Grodzicki, I. Bergh, M. Metra, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology Eur J Heart Fail, May 1, 2009; 11(5): 433 - 443. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. A. Hunt, W. T. Abraham, M. H. Chin, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. Jessup, M. A. Konstam, D. M. Mancini, K. Michl, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation J. Am. Coll. Cardiol., April 14, 2009; 53(15): e1 - e90. [Full Text] [PDF]
|
|
|
|
|
|
M. Jessup, W. T. Abraham, D. E. Casey, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. A. Konstam, D. M. Mancini, P. S. Rahko, M. A. Silver, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation J. Am. Coll. Cardiol., April 14, 2009; 53(15): 1343 - 1382. [Full Text] [PDF]
|
|
|
|
 |
|
 2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDA, M. Jessup, W. T. Abraham, D. E. Casey, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. A. Konstam, D. M. Mancini, P. S. Rahko, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation Circulation, April 14, 2009; 119(14): 1977 - 2016. [Full Text] [PDF]
|
|
|
|
|
|
2005 WRITING COMMITTEE MEMBERS, S. A. Hunt, W. T. Abraham, M. H. Chin, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. Jessup, M. A. Konstam, D. M. Mancini, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation Circulation, April 14, 2009; 119(14): e391 - e479. [Full Text] [PDF]
|
|
|
|
 |
|
 D. Viola, D. C. Leven, and J. C. LePere End-of-life Care: An Interdisciplinary Perspective American Journal of Hospice and Palliative Medicine, April 1, 2009; 26(2): 75 - 78. [Abstract] [PDF]
|
|
|
|
 |
|
 M. Lanoix Palliative care and Parkinson's disease: managing the chronic-palliative interface Chronic Illness, March 1, 2009; 5(1): 46 - 55. [Abstract] [PDF]
|
|
|
|
 |
|
 W. G. Kuschner, D. A. Gruenewald, N. Clum, A. Beal, and S. C. Ezeji-Okoye Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia Chest, January 1, 2009; 135(1): 26 - 32. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. C. Dobratz Word Choices of Advanced Cancer Patients: Frequency of Nociceptive and Neuropathic Pain American Journal of Hospice and Palliative Medicine, January 1, 2009; 25(6): 469 - 475. [Abstract] [PDF]
|
|
|
|
 |
|
 M. K. Buss Palliating Dyspnea for Patients with Cancer ASCO Educational Book, January 1, 2009; 2009(1): 549 - 553. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. H. Von Roenn, F. Strasser, and C. F. von Gunten Update on the Integration of Palliative Care into Cancer Care ASCO Educational Book, January 1, 2009; 2009(1): 590 - 596. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Janssen, M. Spruit, E. Wouters, and J. Schols Daily symptom burden in end-stage chronic organ failure: a systematic review Palliative Medicine, December 1, 2008; 22(8): 938 - 948. [Abstract] [PDF]
|
|
|
|
 |
|
 A. H. Moss, J. Ganjoo, S. Sharma, J. Gansor, S. Senft, B. Weaner, C. Dalton, K. MacKay, B. Pellegrino, P. Anantharaman, et al. Utility of the "Surprise" Question to Identify Dialysis Patients with High Mortality Clin. J. Am. Soc. Nephrol., September 1, 2008; 3(5): 1379 - 1384. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. A. Lorenz Progress in Quality-of-Care Research and Hope for Supportive Cancer Care J. Clin. Oncol., August 10, 2008; 26(23): 3821 - 3823. [Full Text] [PDF]
|
|
|
|
|
|
B. Ferrell, J. Paice, and M. Koczywas New Standards and Implications for Improving the Quality of Supportive Oncology Practice J. Clin. Oncol., August 10, 2008; 26(23): 3824 - 3831. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M. Dy, S. M. Asch, A. Naeim, H. Sanati, A. Walling, and K. A. Lorenz Evidence-Based Standards for Cancer Pain Management J. Clin. Oncol., August 10, 2008; 26(23): 3879 - 3885. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M. Dy, K. A. Lorenz, A. Naeim, H. Sanati, A. Walling, and S. M. Asch Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea J. Clin. Oncol., August 10, 2008; 26(23): 3886 - 3895. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Walling, K. A. Lorenz, S. M. Dy, A. Naeim, H. Sanati, S. M. Asch, and N. S. Wenger Evidence-Based Recommendations for Information and Care Planning in Cancer Care J. Clin. Oncol., August 10, 2008; 26(23): 3896 - 3902. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. P. Aulisio and R. M. Arnold Role of the Ethics Committee: Helping To Address Value Conflicts or Uncertainties Chest, August 1, 2008; 134(2): 417 - 424. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. P. Whitlock, J. S. Lin, R. Chou, P. Shekelle, and K. A. Robinson Using Existing Systematic Reviews in Complex Systematic Reviews Ann Intern Med, May 20, 2008; 148(10): 776 - 782. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Zimmermann, R. Riechelmann, M. Krzyzanowska, G. Rodin, and I. Tannock Effectiveness of Specialized Palliative Care: A Systematic Review JAMA, April 9, 2008; 299(14): 1698 - 1709. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 New ACP Guideline on Palliative Care Journal Watch (General), January 29, 2008; 2008(129): 6 - 6. [Full Text]
|
|
|
|
|
|
A. Qaseem, V. Snow, P. Shekelle, D. E. Casey Jr., J. T. Cross Jr., D. K. Owens, and for the Clinical Efficacy Assessment Subcommittee Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians Ann Intern Med, January 15, 2008; 148(2): 141 - 146. [Abstract] [Full Text] [PDF]
|
|
Read all Rapid Responses
Article
