Evidence for improving palliative care at the end of life: a systematic review.
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.


OBJECTIVE
To assess evidence about interventions to improve palliative and end-of-life care.


METHODS
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.


METHODS
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.


CONCLUSIONS
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.
Lorenz
Karl A
KA
Division of General Internal Medicine, Veterans Integrated Palliative Program, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA. karl.lorenz@med.va.gov
Lynn
Joanne
J
Dy
Sydney M
SM
Shugarman
Lisa R
LR
Wilkinson
Anne
A
Mularski
Richard A
RA
Morton
Sally C
SC
Hughes
Ronda G
RG
Hilton
Lara K
LK
Maglione
Margaret
M
Rhodes
Shannon L
SL
Rolon
Cony
C
Sun
Virginia C
VC
Shekelle
Paul G
PG
D032722:Advance Care Planning / Q000592:standards; D017028:Caregivers / Q000523:psychology; D003266:Continuity of Patient Care / Q000592:standards; D003863:Depression / Q000628:therapy; D004417:Dyspnea / Q000628:therapy; D006801:Humans; D059408:Pain Management; D010166:Palliative Care / Q000592:standards*; D010348:Patient Care Team / Q000592:standards; D012017:Referral and Consultation; D012944:Social Support