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.

30 September 2019

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements

Yarom N, Hovan A, Bossi P, Ariyawardana A, Jensen SB, Gobbo M, et al. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer. 2019 Oct;27(10):3997-4010. doi: 10.1007/s00520-019-04887-x. Epub 2019 Jul 8.
Oral mucositis can be a distressing and difficult to treat side effect of cancer treatments. This systematic review was undertaken as part of a larger project to update clinical practice guidelines for the management of oral mucositis in cancer patients. While not specifically reviewing literature in a palliative care setting this study may be applicable to some patients. 78 studies were included in the review which examined a number of vitamins, minerals and nutritional supplements. Based on this review some recommendations in the guideline have been updated. There is evidence to recommend not using parenteral glutamine to prevent oral mucositis in haematopoietic stem cell transplantation. A new recommendation supports the use of oral glutamine in head and neck cancer patients treated with both radiotherapy and chemotherapy. The authors were unable to make a positive recommendation for the use of zinc as the evidence remains conflicting and so have made a recommendation against its use in patients with head and neck cancer. New studies were reviewed examining the use of vitamin E, selenium, folinic acid and calcitrol but there is limited evidence to make recommendation about using any of these. There is a growing area of research around vitamins, minerals and nutritional supplements and recommendations about their use in the clinical setting are evolving.

30 September 2019

Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review.

Tapp D, Chenacher S, Gérard NPA, Bérubé-Mercier P, Gelinas C, Douville F, et al. Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review. J Palliat Care. 2019 Jan 13:825859718816073. doi: 10.1177/0825859718816073. [Epub ahead of print]
Pain is the most common symptom experienced by patients at the end of life. Assessing pain in patients who cannot speak is a challenge and a number of tools have been developed in a number of settings to help clinicians assess pain in non-verbal patients. This review examined the utility and validity of some of these tools for use in a palliative care setting. Four tools met the authors inclusion criteria – the Pain in Advanced Dementia (PAINAD), the Abbey Pain Scale, both developed for use in people with dementia, the Critical Care Pain Observation Tool (CPOT), developed for use in ventilated patients and the Multidimensional Objective Pain Assessment Tool (MOPAT) which is the only tool developed for the palliative care setting. Some of these tools have been validated for use in other settings, the PAINAD in people with dementia and the CPOT in intensive care patients. All four tools have been partially validated for use in an end-of life clinical setting, but none have been fully validated. This presents a gap in the research evidence and the authors are unable to make a clear recommendation on which tool to use. This study highlights the importance of using validated tools in any setting and the fact that many tools being used today have not been validated for use in palliative care. The CPOT may be the most useful tool to validate in the palliative care setting.

30 September 2019

Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review.

Skelton L, Guo P. Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review. Curr Opin Support Palliat Care. 2019 Sep 3. doi: 10.1097/SPC.0000000000000458. [Epub ahead of print]
Delirium is becoming more prevalent in the palliative care setting and managing it can be difficult. This systematic review examined studies to evaluate the effectiveness of pharmacological and non-pharmacological approaches to managing delirium in the palliative care setting. Six studies were included, three were set in hospitals, and three set in hospices. Four of the studies were RCTs, one a controlled trial and one was a comparative cohort study, including 1958 patients, nearly all of whom had cancer. The treatment approaches examined in the studies were haloperidol, risperidone, olanzapine, lorazepam, aripiprazole and the non-pharmacological approach as a multi-component intervention, which included patient orientation, patient cognitive stimulation, education for staff, and supportive advice for families. The authors acknowledge there is limited research in this area but despite this they are able to make some recommendations. They recommend the implementation of non-pharmacological techniques in mild delirium. For moderate to severe delirium a pharmacological approach is advised and the authors found no one medication superior to another and so recommend an individual approach to management. In agitated delirium, particularly for patients moving towards the terminal phase, there is a role for benzodiazepines along with haloperidol.

3 September 2019

Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis.

Schichtel M, Wee B, MacArtney JI, Collins S. Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis. BMJ Support Palliat Care. 2019 Jul 22. pii: bmjspcare-2018-001747. doi: 10.1136/bmjspcare-2018-001747. [Epub ahead of print]
Many people dying of heart failure are unaware of their prognosis and this systematic review aimed to identify the barriers and facilitators of advanced care planning (ACP) in this group of patients. The authors reviewed 17 studies that specifically examined those elements that enabled or prevented clinicians initiating or completing advanced care planning with patients and their family. This study supported those of previous studies that there is a fundamental degree of uncertainty in the prognosis of end of life in heart failure. The review found that there is a lack of collaboration and agreement between clinicians on when to initiate ACP, that clinicians lack the skills needed to initiate ACP conversations and that these conversations produced a high emotional impact on clinicians. Not wanting to distress patients or take away hope was a major barrier for clinicians initiating ACP. The researchers did, however, identify enablers. ACP was easier when the patient started the conversation and the planning, and when clinicians had developed a relationship with the patient over a long period of time. While the authors conclude that training health care professional in ACP is essential there may be equal benefit in targeting education regarding ACP toward patients. Using tools like question prompt lists may encourage patients with heart failure to discuss their needs at the end of life.

3 September 2019

Fan Therapy for the Treatment of Dyspnoea in Adults: A Systematic Review.

Qian Y, Wu Y, Rozman de Moraes A, Yi X, Geng Y, Dibaj S, et al. Fan Therapy for the Treatment of Dyspnoea in Adults: A Systematic Review. J Pain Symptom Manage. 2019 Sep;58(3):481-486. doi: 10.1016/j.jpainsymman.2019.04.011. Epub 2019 Apr 18.
Dyspnoea is a common symptom at the end of life which can be challenging to manage and distressing to patients. Using a handheld or electric fan has been proposed as one way to relieve dyspnoea. This intervention may work by providing airflow stimulation to the patient’s face, or by cooling the patient, and is a non-invasive, inexpensive and potentially autonomous treatment option. This systematic review examined ten studies, nine randomised controlled studies and one cohort study, including 344 patients. Eight of the ten studies established a benefit for using a fan, with six establishing clinical benefit and two establishing a reduction in the sensation of breathlessness. The other studies were not able to establish any benefit. Most of the studies were set in hospitals and nearly half the participants (n=159) were diagnosed with cancer. The length of time the fan was used was reported in six studies as five minutes, which appears to have been chosen at random. Each of the studies examined used slightly different outcome measures to identify a response to the intervention, which is a limitation to this review. The pool of patients in these studies is quite low and there is a need for larger studies to examine more defined outcomes, such as the duration of effect of using a fan and the role of cooling the patient to relieve symptoms.

3 September 2019

Systematic review of the impact of patient death on surgeons.

Joliat GR, Demartines N, Uldry E. Systematic review of the impact of patient death on surgeons. Br J Surg. 2019 Aug 2. doi: 10.1002/bjs.11264. [Epub ahead of print]
There is limited research on how surgeons face and cope with the death of a patient. Intraoperative mortality continues to fall, surgical training focuses on curing disease and the death of a patient is often seen as surgical failure, making this an area which lacks research. Other medical specialties, such as Oncology and Anaesthesia, have investigated the effects of patient death on their workforce and have shown this can increase the risk of burnout. This systematic review set out to examine the effect of a patients’ death on surgeons and identified seven articles for inclusion. Two of the papers included were opinion pieces which highlighted the lack of palliative care training surgeons receive either as undergraduates or in their speciality post graduate training. The other papers included were research studies, one focusing on Australian surgeons. This identified that a surgeon’s personality influenced their response to a patient’s death and that while some were less affected by the death of a patient with a life-limiting illness, all patient deaths had an emotional impact. This systematic review establishes that new and more experienced surgeons are put under psychological stress when a patient dies and this increases the risk of burnout and depression. Burnout is not specific to any one area of healthcare. Interventions that reduce the risk of burnout include a positive work environment and staff identifying colleagues who may be at risk of developing burnout. Surgeons may be at higher risk of psychological stress due to the lack of training in palliative care and the potential lack of recognition that the death of a patient may be an issue for their colleagues. While this review acknowledges there is an increase in awareness about the impact of a patient’s death on a surgeon, there is still very little research into what the particular needs of this medical group are and what potential interventions may be effective to prevent burnout.

26 August 2019

Challenges and support needs of parents and children when a parent is at end of life: A systematic review.

Hanna JR, McCaughan E, Semple CJ. Challenges and support needs of parents and children when a parent is at end of life: A systematic review. Palliat Med. 2019 Jun 27:269216319857622. doi: 10.1177/0269216319857622.
This review examines the challenges and support needs of parents and dependent children when a parent is at the end of their life. Twenty seven qualitative studies were included and all participants were from a middle class, two parent family. The review found that protecting children from the truth about their parent’s impending death may be a natural parenting instinct but children who are less prepared for the death of a parent have shown increased hostility, resentment and guilt than those who were better prepared. Knowing how much information to share with a child was a challenge for parents and it is not always easy given the uncertainty around the trajectory of illness.
A factor in preparing children was spending time together before the death of their parent. Identifying networks inside and outside the family to provide support to the child was also beneficial for both the child and the dying parent. Knowing that someone would be available to care for their child when they were no longer able to, was comforting to the dying parent. Children responded to positive social support mechanisms such as maintaining routines like going to school or spending time with friends and peers.
More research is needed to reflect the experiences of more diverse families, such as divorced families or those affected by life-limiting illness other than cancer. Implications for health care professionals include the need to provide realistic information about prognosis to support families and to assist parents to openly communicate to their children.

22 August 2019

A Systematic Literature Review of the Current State of Knowledge Related to Interventions for Bereaved Parents.

Dias N, Hendricks-Ferguson VL, Wei H, Boring E, Sewell K, Haase JE. A Systematic Literature Review of the Current State of Knowledge Related to Interventions for Bereaved Parents. Am J Hosp Palliat Care. 2019 Jul 3:1049909119858931. doi: 10.1177/1049909119858931. [Epub ahead of print]
Supporting a parent who has lost a child can be challenging and this review sought to identify interventions for bereaved parents. Nine studies were included in the review, which were of varying quality. The authors noted the difficulty of finding research studies examining interventions for this specific group and they identified the need for more robust and focused research in this area. Of the interventions discussed in the paper those that provided a positive outcome for participants were intentional touch therapy, mindfulness therapy and intensive group therapy. The authors acknowledged the difficulty in recruiting participants into bereavement research projects and in particular the difficulty of recruiting grieving parents. While the authors are unable to make recommendations based on their review of the literature they have made some suggestions regarding design requirements for future studies which may be useful for researchers in this area.

22 August 2019

Prevalence and Incidence of Anxiety and Depression Among Children, Adolescents, and Young Adults With Life-Limiting Conditions: A Systematic Review and Meta-analysis.

Barker MM, Beresford B, Bland M, Fraser LK. Prevalence and Incidence of Anxiety and Depression Among Children, Adolescents, and Young Adults With Life-Limiting Conditions: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019 Jul 8. doi: 10.1001/jamapediatrics.2019.1712. [Epub ahead of print]
This systematic review and meta-analysis sought to estimate the prevalence of anxiety and depression in children, adolescents and young adults (aged 5 to 25 years) with life-limiting conditions. Thirty seven studies were included, 19 reported the prevalence of anxiety while 36 reported the prevalence of depression. A higher rate of anxiety and depression was found in children, adolescents and young adults with life-limiting illnesses compared with the same age groups in the general population. Anxiety was estimated at 19.1 per cent in those with life-limiting illnesses compared to 3 percent in the general population in the United States and 7.2 percent in the United Kingdom. Depression was also higher in the targeted group with 14.3 per cent of those with life-limiting illnesses compared to 2.1 percent in the United States and 8.1 per cent in the United Kingdom. The researchers acknowledged that there was a reporting variation in the studies reviewed depending on the type of assessment tool used, with interviews yielding higher rates of anxiety and self-report tools providing higher rates of depression. While this review does have some limitations, in that only English language studies were reviewed and many studies had small sample sizes, there are some implications which can be drawn. This paper adds to the case in support of routinely screening younger patients for anxiety and depression. It also highlights the evidence gap in relation to younger people with life-limiting illnesses and their mental health needs, and the need for larger scale research in this area.

30 July 2019

Comparative efficacy and acceptability of treatments for restless legs syndrome in end-stage renal disease: a systematic review and network meta-analysis.

Huang CW, Lee MJ, Wang LJ, Lee PT, Tu YK, Hsu CW, et al. Comparative efficacy and acceptability of treatments for restless legs syndrome in end-stage renal disease: a systematic review and network meta-analysis. Nephrol Dial Transplant. 2019 Jun 3. pii: gfz097. doi: 10.1093/ndt/gfz097. [Epub ahead of print]
Restless legs syndrome, or Wills-Ekbom disease occurs in approximately 6 to 50 per cent of patients with end stage renal disease and is characterised as a compulsion to move the limbs, mostly the legs. In this context it is known to be associated with increased risk of depression, anxiety, impaired quality of life, insomnia, and discontinuation of dialysis. This systematic review and network meta-analysis of 12 RCTs examining the efficacy of interventions at treating the syndrome included 498 patients. Of the nine interventions examined, Gabapentin provided the greatest alleviation of symptoms with an acceptable risk of side effects. Dopamine agonists when combined with exercise therapy was more effective than vitamin C, vitamin E or both given in combination. While iron supplementation also proved beneficial at reducing symptoms it did not have sustained effects. The authors of this review note that all the RCTs reviewed were of short duration and they did not consider the baseline severity of symptoms when comparing treatment outcomes.

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