A study commissioned to help guide revisions of best practices in providing palliative care finds that there is a wide and varied body of evidence to support such clinical practice guidelines.
The systematic review by researchers from the RAND Corporation found that the research base for palliative care was larger than generally appreciated, although there was limited evidence across some areas of clinical practice such as how to care for patients during the last days of their lives.
Published in the Journal of Pain and Symptom Management, the study was conducted to support the fourth edition of the National Consensus Project's Clinical Practices Guidelines for Quality Palliative Care, which establishes best practices in end-of-life care. While previous guidelines have been developed through consensus among experts, the systematic review was incorporated into the just-released fourth edition of the guidelines.
"Our review will help guide best practices going forward and help focus future research efforts to build a high-quality evidence base for end-of-life care," said Sangeeta Ahluwalia, the study's lead author and a senior policy researcher at RAND, a nonprofit research organization. "While the palliative care evidence base has been rapidly growing, we now better understand where there are gaps."
Palliative care is a rapidly growing field aimed at improving quality of life for patients with serious illness and their caregivers. Inpatient palliative care programs have increased sharply in recent years, with two-thirds of hospitals with 50 or more beds reporting that they have an interdisciplinary palliative care team.
Researchers from the Southern California Evidence-based Practice Center at RAND reviewed the research literature to assess the status of evidence across eight domains of palliative care: the structure and process of care; physical aspects of care; psychological aspects of care; social aspects of care; spiritual, religious and existential aspects of care; cultural aspects of care; care of the patient nearing the end of life; and ethical and legal aspects of care.
The most promising approaches to palliative care structure and process identified by the review include home-based palliative care, interdisciplinary team care and telehealth interventions. The findings support continued growth in these areas, with attention needed on workforce expansion, quality assessment of these services and innovative payment models.
The study also found there is now documented evidence for comprehensive palliative care and music/art therapy addressing physical and psychological aspects of care. However, the existing evidence base for social needs assessments and culturally-sensitive care remains very limited.
There is also documented evidence that grief and bereavement support services appear to improve key outcomes for caregivers, but the evidence base for effective approaches for care focused on the last days of life is very limited.
Evidence for physician orders and advance directive interventions showed the strongest evidence in the ethical and legal aspects of care domain. Ethics consultations improve consensus in the intensive care unit, which can help reduce use of high-intensity and often life-prolonging treatments at the end of life.
"Our review documents a substantial body of evidence to support clinical practice guidelines for palliative care, but the quality of evidence remains limited," said Susanne Hempel, the study's senior author and co-director of the Evidence-based Practice Center at RAND. "This comprehensive review underscores the importance of targeting future research toward building high-quality evidence in key areas of clinical practice, and patient and caregiver needs."
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The systematic review was sponsored by the National Coalition for Hospice and Palliative Care and funded by the Gordon and Betty Moore Foundation, the Gary and Mary West Foundation, The John A. Hartford Foundation and the Stupski Foundation.
Other authors of the study are Christine Chen, Laura Raaen, Aneesa Motala, Margaret Chamberlin, Claire O'Hanlon, Jody Larkin and Olamigoke Akinniranye, all of RAND, Anne M. Walling of the David Geffen UCLA School of Medicine, and Karl Lorenz of the Stanford University School of Medicine.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.09.008
