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.

9 November 2020

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis.

Mills SEE, Geneen LJ, Buchanan D, Guthrie B, Smith BH. Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis. BMJ Support Palliat Care. 2020 Oct 13:bmjspcare-2020-002410. doi: 10.1136/bmjspcare-2020-002410. Epub ahead of print.

For people dying with cancer unscheduled care is disruptive. Knowledge of modifiable factors influencing need for unscheduled care might help to minimise these events and identifying factors that cannot be modified help to target efforts. This review of 47 articles found evidence that for people with cancer unscheduled visits are more likely with lung cancer, for pain or breathlessness, and among people receiving radiotherapy towards the end of life. The review also found consistent evidence that unscheduled events are less likely with improved access to analgesia and community-based palliative care, and ongoing GP involvement in care. There was also moderate level evidence for improvement with GP home visits and structured symptom and symptom management training for carers.  Addressing some of these modifiable factors may already help some patients with cancer avoid the disruption of unscheduled visits towards the end of their lives.

9 November 2020

Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

Quinn KL, Shurrab M, Gitau K, Kavalieratos D, Isenberg SR, Stall NM, et al. Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis. JAMA. 2020 Oct 13;324(14):1439-1450. doi: 10.1001/jama.2020.14205.

In the last four years outcomes from at least 10 trials of palliative care in patients with non-cancer illness have been published. This prompted the authors of this review to examine the evidence for this group in relation to palliative care and acute care use, quality of life (QoL) and symptom burden. Their detailed meta-analysis reveals that recieving palliative care support is significantly associated with less health care use and moderately lower symptom burden. But the available evidence was insufficient to draw conclusions for advance care planning or QoL. While the authors discuss study heterogeneity as a barrier to examining these relationships, they also note that outcomes were improved when the largest study was omitted. That this study was at high risk of bias and involved non-specialist palliative care while most others involved specialists is interesting but far from conclusive. This and comments on the influence palliative care may be having on today’s ‘usual care’ standard and how this might be impacting study outcomes is something many will find of interest.

9 November 2020

Patients' experiences of eHealth in palliative care: an integrative review.

Widberg C, Wiklund B, Klarare A. Patients' experiences of eHealth in palliative care: an integrative review. BMC Palliat Care. 2020 Oct 14;19(1):158. doi: 10.1186/s12904-020-00667-1.

Recently, people with palliative care needs, like many others, have had to find new ways to connect with their care providers. So, this new systematic review of palliative care patient experience of eHealth is timely. With a focus on telemedicine, the review of 12 articles found evidence of mostly positive patient experiences. Age was not a barrier, and video links and apps were found to be convenient and particularly supportive of at home palliative care. The potential to use this technology to improve the experience of patients is highlighted. For example, in-built language translation applications enhanced communication in new ways and the technology platform empowered patients by giving them a greater sense of control over their contact with care providers. However, eHealth uptake by patients was found to be strongly influenced by health professional attitudes towards the technology and reminds us of the critical role of this relationship. This review should encourage increased engagement with a technology that has already arrived.

9 October 2020

Trajectories of disability in activities of daily living in advanced cancer or respiratory disease: a systematic review.

Fettes L, Neo J, Ashford S, Higginson IJ, Maddocks M. Trajectories of disability in activities of daily living in advanced cancer or respiratory disease: a systematic review. Disabil Rehabil. 2020 Sep 22:1-12. doi: 10.1080/09638288.2020.1820587. Epub ahead of print.

Disability in activities of daily living (ADL) is common in advanced cancer or respiratory disease, but is it inevitable and given its impact on quality of life what can we do and how do we assess level of disability? Based on 11 studies published before 2012 the authors of this review have addressed these questions and revealed three ADL-related trajectory types for this cohort: unchanging disability, fluctuating disability, and increasing disability. Among the findings it was also noted that increasing disability does not always indicate approaching death, and cancer and respiratory disease are associated with all three trajectories. Factors influencing ADL disability were found to be varied and available research suggests this may include factors that can be modified. Newer research is needed in current contexts of care, but these are important findings that should already prompt clinicians to reconsider acceptance of ADL disability as inevitable and/or always indicative of approaching death.

9 October 2020

Clinical aspects of palliative sedation in prospective studies. A systematic review.

Arantzamendi M, Belar A, Payne S, Rijpstra M, Preston N, Menten J, Van der Elst M, Radbruch L, Hasselaar J, Centeno C. Clinical aspects of palliative sedation in prospective studies. A systematic review. J Pain Symptom Manage. 2020 Sep 19:S0885-3924(20)30754-5. doi: 10.1016/j.jpainsymman.2020.09.022. Epub ahead of print.

Palliative sedation may be considered for intolerable symptoms that are not alleviated with usual approaches at the end of life.   In preparation for a prospective trial on this topic the authors of this review examined available evidence and found that the most common symptoms triggering palliative sedation were delirium, pain and dyspnoea, most groups followed the EAPC guidelines, and first line medication was usually Midazolam. They also revealed that although the aim was to relieve refractory symptoms few studies measured patient discomfort and the role of artificial hydration and level of appropriate sedation remain uncertain and variable. This review should provoke thinking around palliative sedation and how it is currently approached including its reliance on varied expert opinions.

9 October 2020

Earlier multidisciplinary palliative care intervention for people with lung cancer: a systematic review and meta-analysis.

Kochovska S, Ferreira DH, Luckett T, Phillips JL, Currow DC. Earlier multidisciplinary palliative care intervention for people with lung cancer: a systematic review and meta-analysis. Transl Lung Cancer Res. 2020 Aug;9(4):1699-1709. doi: 10.21037/tlcr.2019.12.18.

With calls for earlier referral to palliative care for everyone with serious illness it is important to establish whether this is of benefit to the person and their carers before resources are committed. This review examined this question in the context of advanced lung cancer. Outcomes based on data from 11 trials were mixed, but overall trends with early specialist or individualised palliative care delivery compared to usual care suggested that survival, quality of life, and level of depression may improve. However, this was not the case for clinical symptoms or self-efficacy. Far from a clear case of benefit this study shows that we need to improve understanding of who might benefit from early palliative care and in what context. In view of these findings and other available evidence, the authors question whether on-demand needs-based access may be a better alternative than early palliative care for all. By targeting limited resources to areas of need it might also improve effectiveness.

4 September 2020

Dyspnoea Assessment In Adults With End-Stage Kidney Disease: A Systematic Review.

Chilvers M, Johnston K, Ferrar K, Williams MT. Dyspnoea Assessment In Adults With End-Stage Kidney Disease: A Systematic Review. J Ren Care. 2020 Sep;46(3):137-150. doi: 10.1111/jorc.12321. Epub 2020 Feb 12.

Chilvers et al note that dyspnoea prevalence ranges from 20 to 100% among people with end stage kidney disease (ESKD) and is associated with a negative prognosis. To support timely access to palliative care for this patient group, here they have examined the evidence for dyspnoea assessment tools. Of 12 instruments nine were comprehensive, and of these, four assessed symptom burden in chronic kidney disease (CKD) and palliative care. However, despite dyspnoea being recognised as a subjective symptom no tool asked patients what it “feels’ like or examined quality of life. In line with a limited evidence base the authors found that clinical guidelines for ESKD fail to mention dyspnoea. In 2017-18 there were 1.8 million CKD associated hospitalisations in Australia. This review reminds clinicians that dyspnoea is likely to be experienced by many of those people and this may offer an opportunity to improve access to palliative care and the evidence base.

4 September 2020

Pharmacist-led medication reviews in aged care residents with dementia: A systematic review.

McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. Pharmacist-led medication reviews in aged care residents with dementia: A systematic review. Australas J Ageing. 2020 Aug 4. doi: 10.1111/ajag.12827. Epub ahead of print.

Ageing is associated with changes in metabolism that affect medications, and more than half of residential aged care (RAC) residents with dementia take five or more medications. Add to this a high turnover of staff and it is easy to understand current interest in RAC models of care involving pharmacist led medication review for people with dementia. In examining the evidence for this model McDerby et al found it to be small in volume and of poor quality but nevertheless outcomes were encouraging for pharmacist-led review with multi-disciplinary collaboration and education. One of the biggest barriers was physician reluctance to implement pharmacist recommendations. When this was overcome benefits for the person with dementia included reduced number of medications and improved appropriateness of psychotropic prescribing. More robust evidence is still needed but these findings might already inform quality improvement projects in RAC where the multidisciplinary approach has been embraced.

4 September 2020

Palliative care needs-assessment and measurement tools used in patients with heart failure: a systematic mixed-studies review with narrative synthesis.

Remawi BN, Gadoud A, Murphy IMJ, Preston N. Palliative care needs-assessment and measurement tools used in patients with heart failure: a systematic mixed-studies review with narrative synthesis. Heart Fail Rev. 2020 Aug 3. doi: 10.1007/s10741-020-10011-7. Epub ahead of print.

With increasing demand for palliative care and the varied needs and circumstances of those who might benefit there are clear advantages to having reliable measures to assess individual patient needs.  Remawai et al set out in this review to examine available tools for people with heart failure (HF). Based on 27 articles they identified six well known palliative care needs-assessment and measurement tools frequently referred to in the literature and used in practice. However, only two of those tools covered all palliative care domains and only one had been validated for use in HF. While recommending NAT:PD-HF as the tool of choice in HF, this review is relevant to other patient groups. The authors’ detailed examination of the origin and development of these common tools poses questions about how they are being used and suggests that an approach based on a combination of tools might be more appropriate.