Palliative Care

• STUDY PURPOSE: To examine the outcomes, experiences, and therapeutic components of holistic services. Definition of holistic services: “drawing on skills from multiple specialties and disciplines; using a holistic approach encompassing nonpharmacologic and pharmacologic interventions as indicated; and supporting self-management.”
• TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: 9 
• YEARS INCLUDED: Database inception to June 2017
• INCLUSION CRITERIA: RCT, non-RCT, observational, and qualitative studies were included
• EXCLUSION CRITERIA: Grey literature

• TOTAL REFERENCES RETRIEVED: 3,239
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Good methods, protocol registered in Prospero, and PRISMA methods followed.

• FINAL NUMBER STUDIES INCLUDED: 37 
• TOTAL PATIENTS INCLUDED IN REVIEW: Not reported as an aggregate, but individual studies described in tables
• SAMPLE RANGE ACROSS STUDIES: Described in tables
• KEY SAMPLE CHARACTERISTICS: Most patients had advanced cancer

• PHASE OF CARE: End-of-life care     
• APPLICATIONS: Palliative care

Interventions represented 18 different services. Most services enrolled people with thoracic cancer, involved palliative care staff, and comprised 4–6 contacts over 4–6 weeks. Commonly used interventions included breathing techniques, psychological support, and relaxation techniques. Meta-analyses demonstrated reductions in Numeric Rating Scale distress due to breathlessness (n = 324; mean difference (MD) = −2.30, 95% CI [−4.43, −0.16], p = 0.03) and Hospital Anxiety and Depression Scale (HADS) depression scores (n = 408, MD = −1.67, 95% CI [−2.52, −0.81], p < 0.001). Statistically non-significant effects were observed for Chronic Respiratory Questionnaire (CRQ) mastery (n = 259, MD = 0.23, 95% CI [−0.1, 0.55], p = 0.17) and HADS anxiety scores (n = 552, MD = −1.59, 95% CI [−3.22, 0.05], p = 0.06). Patients and caregivers valued tailored education, self-management interventions, and expert staff providing person-centered, dignified care. There was no observable effect on health status or quality of life, and mixed evidence around physical function.

Evidence suggests an effect of integrative palliative care on the affective domain of breathlessness, and on psychological outcomes of anxiety and depression. Services were highly valued by patients and caregivers, who appreciated the education to help them understand their breathlessness, the provision of useful self-management interventions, and the provision of expert dignified care which centered on the person. No effect on overall health status or quality of life using generic measures and mixed evidence around any effect on physical function was identified

Integrative palliative care may provide a benefit to patients with advanced cancer.

To determine symptom changes after outpatient palliative care

Patients who were seen in outpatient palliative care and had completed a symptom assessment scale were included in retrospective review of medical records. Only patients who completed the assessment and had at least one follow-up visit were included. The outpatient palliative care service was provided by an interdisciplinary team. Baseline symptom severity was compared to findings on an initial follow-up—usually in 15 days—and compared to a group of patients not eligible for study inclusion.

• N = 1,612 
• MEAN AGE = 59.2 years (SD = 13.2 years)
• MALES: 52%, FEMALES: 48%
• KEY DISEASE CHARACTERISTICS: Multiple disease types; lung, gastrointestinal, and genitourinary cancers were most frequent.
• OTHER KEY SAMPLE CHARACTERISTICS: 73% were Caucasian.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: MD Anderson in Texas

• APPLICATIONS: Palliative care

• Retrospective, descriptive

• Edmonton Symptom Assessment Scale

Of the patients, 52%–74% had improvement in intensity of symptoms of pain, fatigue, depression, anxiety, anorexia, shortness of breath, and sleep disruption. Overall, among patients who had no or mild symptoms at baseline, symptom intensity was worse at follow-up, and among those with moderate or severe symptoms, symptom intensity declined at follow-up. Of patients with moderate or severe symptoms, 48%–80% continued to have clinically significant symptom intensity at follow-up. Median scores for pain, fatigue, depression, anxiety, anorexia, dyspnea, and sleep disturbance improved by at least one point by the first follow-up (p < .001).

Outpatient palliative care services in this setting were associated with reduced symptom intensity among patients who had moderate to severe symptoms. Findings suggest that the timing of initial follow-up might not be sufficient to significantly reduce symptom burden quickly.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Selective outcomes reporting
• Other limitations/explanation: Retrospective design; no information provided regarding disease stage or phase of cancer care involved; only a single follow-up time point

Findings suggest that provision of outpatient palliative care services can be beneficial in reducing symptom burden among patients with cancer. Because 48%–80% still had relatively high intensity of symptoms at follow-up after 15 days—and those with no or mild symptoms had exacerbation of symptoms at follow-up—a shorter initial follow-up period might achieve more rapid improvement and help to prevent exacerbation of symptoms. Findings also suggest that getting more severe symptoms under control may take longer, pointing to the need for nurses to consider involvement of palliative care specialists early in the course of cancer treatment.