Highlighted Reviews

The following selected systematic reviews have been reviewed by the CareSearch team to highlight the relevance of this research to palliative care practice and the Australian context where appropriate.  For the full list of new reviews added to the CareSearch Systematic Review collection visit the Latest Reviews page.

7 May 2020

Triggered Palliative Care Consults: A Systematic Review of Interventions for Hospitalized and Emergency Department Patients.

Kistler EA, Stevens E, Scott E, Philpotts LL, Greer JA, Greenwald JL. Triggered Palliative Care Consults: A Systematic Review of Interventions for Hospitalized and Emergency Department Patients. J Pain Symptom Manage. 2020 Feb 12:S0885-3924(20)30074-9. doi: 10.1016/j.jpainsymman.2020.02.001. Epub ahead of print.

How do we identify who would benefit from a palliative care consultation? This review of 20 studies with more than 17,000 patients examined the trigger tools commonly employed to make this decision when patients present to an emergency department or have been admitted to hospital. Approximately 40% of patients were identified as likely to benefit. The most common categories included in the tools were the presence of advanced or life-limiting disease such as cancer or chronic comorbidities, readmission risk, and goals of care discussions. In total 20 categories were identified but no category was present in all studies, while expert opinion and local observation were the basis of most tools. The authors discuss this heterogeneity and propose a base set of categories that might inform development of a standardised tool.  This is important in terms of improving identification of those who might benefit, and because not all care settings have experts and experience to guide local tool development.

7 May 2020

The use of olanzapine as an antiemetic in palliative medicine: a systematic review of the literature.

Saudemont G, Prod'Homme C, Da Silva A, Villet S, Reich M, Penel N, Gamblin V. The use of olanzapine as an antiemetic in palliative medicine: a systematic review of the literature. BMC Palliat Care. 2020 Apr 22;19(1):56. doi: 10.1186/s12904-020-00559-4.

Nausea is a common symptom towards the end of life and the use of antiemetics to manage this is well established. However, the appropriateness of medications also depends on the individual person’s tolerance and capacity for different drugs and routes of administration. Having a range of options helps to accommodate this while maintaining good symptom management. Keeping up with the evidence base underpinning these options is part of best practice care and alerts us where new practices or research is required.  This detailed review of 13 articles examined the evidence for use of the antipsychotic olanzapine as an antiemetic in palliative care. Currently recommended for chemotherapy induced nausea and vomiting, the authors provide a useful review of olanzapine relative to other antiemetics and discuss the evidence for its efficacy and applicability in palliative care. Overall the available studies support use of olanzapine but the evidence base in the context of palliative care is very low. This article shows how emerging evidence for new treatments can be clearly presented within the context of current practice. It also demonstrates how knowledge of the evidence level influences whether changes in practice are needed.

7 May 2020

Medication use in aged care residents in the last year of life: A scoping review.

Aitken C, Boyd M, Nielsen L, Collier A. Medication use in aged care residents in the last year of life: A scoping review. Palliat Med. 2020 Apr 14:269216320911596. doi: 10.1177/0269216320911596. Epub ahead of print.

People increasingly approach old age and end of life with multiple chronic conditions. This makes striking a balance between prescribing for the chronic illness and for end of life symptom management difficult as the number of medications increases. This is particularly so in residential aged care facilities (RACF) where many of the residents are physically and cognitively frail as they approach their end of life. This scoping review of 30 studies examined the characteristics of medication use in the last year of life within RACF. Some common findings were apparent such as the use of opioids and non-opioid analgesics as death approached, although people with dementia were less likely to receive these.  A high level of preventative medication prescribing in the last year of life was also common as was the practice of deprescribing as the person neared the end of life. Overall the authors provide a useful discussion of polypharmacy in the RACF context and suggest that it is more complex than the number of medications. Indeed more studies reported on the appropriateness of medications rather than number, although as highlighted here currently available tools to measure this use different criteria and can give very different rates. Future systematic review of studies within a common health and aged care system can now build on this insight to provide the detail required to inform practice.

9 April 2020

Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease

Kapnadak SG, Dimango E, Hadjiliadis D, Hempstead SE, Tallarico E, Pilewski JM, et al. Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease. J Cyst Fibros. 2020 Feb 27:S1569-1993(20)30064-3. doi: 10.1016/j.jcf.2020.02.015. Epub ahead of print.

With recent improvements in quality of life and life expectancy among people with cystic fibrosis (CF) including the increasing availability of lung transplants, the needs of individuals with advanced cystic fibrosis lung disease (ACFLD) may be overlooked. However, ACFLD is the most frequent cause of death among people with CF. This article reports on 23 recommendations made to address the needs of people with ACFLD. The findings are based on a systematic review of the literature and expert consensus. The first of these recommendations relates to palliative care and the need for routine advance care planning and communication around prognosis and goals of care. The review found unique barriers to these processes in the case of ACFLD including variable disease progression, rapid deterioration, and apparent conflict between ACP and patient interest in lung transplantation. As noted in the review early introduction of palliative care in this context is associated with improvements including ACP completeness, symptom management, and reduced healthcare utilisation. While the remaining 22 recommendations usefully centre on care management and assessment, the placement of palliative care should not be overlooked. It reminds us that people with ACFLD have reduced quality of life and worsening clinical symptoms, and that benefit can be gained from palliative care provided in parallel with ongoing treatment including transplantation.

9 April 2020

Cross-cultural dementia screening using the Rowland Universal Dementia Assessment Scale: a systematic review and meta-analysis

Nielsen TR, Jørgensen K. Cross-cultural dementia screening using the Rowland Universal Dementia Assessment Scale: a systematic review and meta-analysis. Int Psychogeriatr. 2020 Mar 9:1-14. doi: 10.1017/S1041610220000344. Epub ahead of print.

With population ageing the worldwide prevalence of dementia is increasing. Globally the anticipated number of people with dementia by 2050 is an estimated 115 million people. Assessment is an important part of dementia management and validated tools are key components of ensuring access to needed support including palliative care. The Rowland Universal Dementia Assessment Scale (RUDAS) was first developed and validated in Australia for use with culturally and linguistically diverse populations. Since then it has found worldwide applicability and acceptability including in settings for which it was not designed such as low- and medium-income countries. The aim of this review of 26 studies in 18 different countries was to quantitatively assess the accuracy of RUDAS and compare performance against other instruments across community, outpatient clinic, and hospital settings in high-, and low- and middle-income countries. Detailed meta-analysis showed that diagnostic accuracy of RUDAS was comparable across settings and across educational levels. Diagnostic performance was comparable to the Mini-Mental State Examination (MMSE). It is interesting to note that all but three studies applied a direct translation of the RUDAS instrument without modification. This, together with demonstrated suitability for people with less education, likely explains the increasing popularity of this tool. While further development and refinement of RUDAS has been suggested, the evidence strongly supports broad application of the current tool across geographical, socioeconomic, and clinical settings.

9 April 2020

Measuring the Efficacy of Occupational Therapy in End-of-Life Care: A Scoping Review.

Chow JK, Pickens ND. Measuring the Efficacy of Occupational Therapy in End-of-Life Care: A Scoping Review. Am J Occup Ther. 2020 Jan/Feb;74(1):7401205020p1-7401205020p14. doi: 10.5014/ajot.2020.033340.

According to the authors of this scoping review, the place of occupational therapy (OT) in end-of-life (EoL) care remains variable due in part to the lack of evidence on efficacy. To understand why that is the case they investigated how efficacy is being measured in studies of OT at EoL. Based on seven articles, the authors noted a lack of consistency around outcome measures, with no two studies using the same measure. However, all studies used ipsative measures (participants' self-reported outcomes against personal levels rather than norms of a general population) which help to accommodate variable performance outcomes among people at EoL. It was also noted that non-controlled study designs were generally used to accommodate small sample size and short follow up periods which related to participant limitations including functional decline and death. Across the studies positive outcomes were reported with OT intervention. But, the authors note that the focus on occupational performance, particularly self-care ADLs, rather than occupational participation fails to accommodate for participant decline and this could affect overall reported impact. For the future, the authors suggest that demonstration of OT efficacy requires research to develop and apply common ipsative outcome measures with psychometric strength and clinical utility to assess occupational participation. It might also benefit from greater attention to environmental contexts and how they influence an individual’s engagement. Perhaps these insights can guide future efforts to develop a more robust evidence base in support of these promising OT interventions in EoL care.

6 March 2020

Specialist palliative care services for older people in primary care: A systematic review using narrative synthesis.

de Nooijer K, Penders YW, Pivodic L, Van Den Noortgate NJ, Pype P, Van den Block L. Specialist palliative care services for older people in primary care: A systematic review using narrative synthesis. Palliat Med. 2020 Jan;34(1):32-48.

Older people attending primary care services increasingly present with multiple chronic conditions some of which are life-limiting. Many do not need specialist care, but if needed how is the decision made to refer to specialist palliative care? This was one of four questions addressed in this systematic review which also examined what specialist care is received following referral. Based on ten articles from multiple countries (not Australia) it was found that referral is generally guided by the person’s age and/or diagnosis. It was not based on their needs and symptoms. Analysis for each of the articles with reference to the remaining three questions around specialist care was used to highlight who was involved, what the outcomes of care were, and how provision of care could be improved. This review prompts reflection on the place of patient needs in referral decisions and suggests ways that better information flow and support might improve patient, carer, and family experience following referral.

6 March 2020

The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature.

Gerson SM, Koksvik GH, Richards N, Materstvedt LJ, Clark D. The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature. J Pain Symptom Manage. 2019 Dec 24:S0885-3924(19)31066-8.

As Australian States and Territories proceed with or explore legislation to allow voluntary assisted dying (VAD) the relationship of this with palliative care is a natural topic of discussion. This review of 16 articles reporting on the relationship in countries where VAD is lawful found that it varies from coexisting in an often synergistic way (Belgium) to complex, with one country simultaneously ambivalent, cooperative and opposed (Switzerland). While this review provides insights into what has shaped development of these different relationships, it also highlights the need for research to answer the many questions raised. Research that is often lacking even in countries with decades of experience in VAD.

6 March 2020

'It's not what they were expecting': A systematic review and narrative synthesis of the role and experience of the hospital palliative care volunteer.

Bloomer MJ, Walshe C. 'It's not what they were expecting': A systematic review and narrative synthesis of the role and experience of the hospital palliative care volunteer. Palliat Med. 2020 Feb 17:269216319899025.

Volunteers make a major contribution across Australia, including in palliative care. This review of 14 articles from multiple countries (but not Australia) examined what is known about hospital palliative care volunteers. Primarily female and often receiving minimal education for their role, it was found that volunteers took on varied roles in the hospital environment but had limited time to develop relationships with patients. Little is known of their impact on patients and family members. Health professionals held a generally positive view of volunteers and appreciated the psychosocial support they provided for patients yet did not value them highly as part of the team. For health professionals and for volunteers themselves, the review prompts reflection on the role of palliative care volunteers and how they might be supported in the hospital environment. 

6 March 2020

International palliative care research priorities: A systematic review.

Hasson F, Nicholson E, Muldrew D, Bamidele O, Payne S, McIlfatrick S. International palliative care research priorities: A systematic review. BMC Palliat Care. 2020 Feb 3;19(1):16.

The authors of this review note that historically palliative care receives only a small proportion of allocated research funding. Coordination of effort and setting of priorities can help to direct finite resources, and within and between countries this has been done through various groups involved in palliative care research. So, what are the international palliative care research priorities in Western countries? From more than 10,000 articles only ten were identified that addressed this question. Review revealed seven broad themes which mapped to priorities associated with process (care delivery), structure (physical and organisational characteristics), and the effects on patient outcomes. Provider perspectives dominated the setting of research priorities, a finding that may explain why priorities tended to involve process and structure based needs not quality of life or symptom management. This review is a first step towards mapping and communicating international research priorities. It encourages more dialogue and a structured approach to priority setting that includes patient, carer, and family needs.