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Clinical Guidelines: Karl A. Lorenz, Joanne Lynn, Sydney M. Dy, Lisa R. Shugarman, Anne Wilkinson, Richard A. Mularski, Sally C. Morton, Ronda G. Hughes, Lara K. Hilton, Margaret Maglione, Shannon L. Rhodes, Cony Rolon, Virginia C. Sun, and Paul G. Shekelle Evidence for Improving Palliative Care at the End of Life: A Systematic Review Ann Intern Med 2008; 148: 147-159 [Abstract] [Full text] [PDF]

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Evidence for improving palliative care at the end of life

Anthony T Kerigan   (4 March 2008)

Evidence for improving palliative care at the end of life 4 March 2008
Anthony T Kerigan, MB,BS; MSc McMaster University,Hamilton,Ontario Send rapid response to journal: Re: Evidence for improving palliative care at the end of life Kerigan{at}mcmaster.ca Anthony T Kerigan	The recent review in the Annals of evidence of palliative care brings to light some of the challenges of summarising evidence in this area(1). The evidence that the authors have assembled supporting recommendations for the treatment of dyspnea in COPD illustrate these challenges. Firstly,in defining end of life,there is much variability leading to incorporation of evidence from various stages of the natural history. Only one review in this area,examining opiods,focused on end of life(2). The others cited are drawn from studies of stable,but not end of life,COPD,which may,but not neccessarily, be applicable to patients with end stage COPD. Secondly,the danger of "lumping" leads to a variety of conditions,COPD,heart failure,and advanced cancer,being included in the review of treatment of dyspnea(2) It is unlikely that the same mechanisms are responsible for dyspnea in all groups or that a particular treatment would have similar effects. In fact ,if the four studies of COPD are examined separately,they are not supportive of the positive recommendation of this review. There will always be difficulties in studying the efficacy of interventions in the terminal phase of chronic conditions such COPD and heart failure. Extrapolation from studies in the more stable but less severe stages will need to made but with due allowance for the individual needs of the patient. 1.Lorenz KA,Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA et al. Evidence for improving palliative care at the end of life :A systematic review. Ann Intern Med. 2008;148:147-159 2.Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A systematic review of the use of opiods in the management of dyspnea. Thorax. 2002;57:939-944 Conflict of Interest: None declared