Evidence-Based Medicine Works Best When There is Evidence: Challenges in Palliative Medicine When Randomized Controlled Trials are not Possible

What do we know about different models of providing palliative care? Findings from a systematic review of reviews

BACKGROUND

A wide range of organisational models of palliative care exist. However, decision makers need more information about which models are likely to be most effective in different settings and for different patient groups.

AIM

To identify the existing range of models of palliative care that have been evaluated, what is already known and what further information is essential if the most effective and cost-effective models are to be identified and replicated more widely.

DESIGN

A review of systematic and narrative reviews according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, Web of Science and ASSIA were searched for reviews about models of service provision from 2000 to 2014 and supplemented with Google searches of the grey literature.

RESULTS

Much of the evidence relates to home-based palliative care, although some models are delivered across care settings. Reviews report several potential advantages and few disadvantages of models of palliative care delivery. However, under-reporting of the components of intervention and comparator models are major barriers to the evaluation and implementation of models of palliative care.

CONCLUSION

Irrespective of setting or patient characteristics, models of palliative care appear to show benefits and some models of palliative care may reduce total healthcare costs. However, much more detailed and systematic reporting of components and agreement about outcome measures is essential in order to understand the key components and successfully replicate effective organisational models.

Hypnosis for Symptom Control in Cancer Patients at the End-of-Life: A Systematic Review

Hypnosis has been shown to alleviate symptoms and side effects of cancer and its treatment. However, less is known about the use of hypnosis at the end of life in individuals with cancer. Our goal was to systematically review the literature on the use of hypnosis to manage the most common symptoms of end-of-life cancer patients: fatigue, sleep disturbances, pain, appetite loss, and dyspnea. EMBASE, MEDLINE, COCHRANE, PsychINFO, and SCOPUS databases were searched from inception through November 7, 2016. No studies met the inclusion criteria. It appears that hypnosis has never been rigorously tested as a means to ameliorate the most common symptoms in individuals with cancer at the end of their lives. This finding is troubling, as it strongly implies that a population most in need has been largely neglected. However, a clear future research direction is revealed that may have significant clinical impact.

Drug therapy optimization at the end of life

Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.

Qualitative research in evidence-based medicine: improving decision-making and participation in randomized controlled trials of cancer treatments

BACKGROUND

Since the 1990s there has been increasing emphasis on 'evidence-based medicine'. The randomized controlled trial is widely regarded as the 'gold-standard' study design for evaluating interventions. However, placing too strong an emphasis on a phase III trial, to the neglect of earlier development and piloting work, may result in weaker interventions that are more difficult to evaluate and less likely to be implemented.

AIM

To illustrate the benefits and outcomes of qualitative research at the early stages of the research continuum.

SETTING/PARTICIPANTS

Two cancer studies are evaluated in which the best treatment option is uncertain: ASPECTS (A Study of Patients ExperienCes of TreatmentS) and ProtecT (Prostate Testing for Cancer and Treatment).

DESIGN

To examine decision-making in relation to palliative chemotherapy for advanced cancer, ASPECTS was a qualitative study involving non-participant observation and recording of oncology consultations. During the ProtecT feasibility study, recruitment interviews were routinely audiotaped and in-depth interviews conducted with men to explore their understanding of treatment options and randomization to trial arms.

RESULTS

ASPECTS identified that insufficient information was given to patients about the survival benefits of palliative chemotherapy with implications for informed consent. ProtecT illustrated the effective use of qualitative research methods to resolve recruitment and randomization problems for a randomized controlled trial.

CONCLUSIONS

These studies illustrate the value of qualitative research, particularly during the earlier phases of the research continuum. Such research may generate hypotheses, strengthen the development and implementation of interventions and enhance their evaluation: all of which are essential to evidence-based medicine.

Methodological challenges in supportive and palliative care cancer research

As a growing medical field, palliative and supportive care should incorporate evidence-based medical practice. The gold standard research method continues to be the randomized clinical trial. This has been pursued with regard to cancer trials focused on cure. It has specific operational and methodological challenges in advanced disease. There are numerous reasons why effective research in palliative and supportive care is difficult. A consensus on the best research strategies and design is lacking. We will discuss the principles of palliative and supportive care research, examine the inherent challenges particularly in randomized controlled trials, and offer some suggestions to overcome them.

Role of Palliative Care in Adolescent and Young Adult Oncology

Adolescents and young adults (AYAs) with cancer are a heterogeneous group. Nevertheless, there are sufficient unifying characteristics to form a distinct clinical entity. Management of this special group requires a broad-based interdisciplinary clinical team, which should include palliative care (PC), psychology, social work, oncology, and nursing representatives. The function of PC is to provide impeccable pain and other symptom control and to coordinate care as the disease progresses. Features unique to AYAs with cancer include the psychosocial developmental phases, a young person facing death, grief, and bereavement. Pharmacologic and medical interventions by PC in AYAs are broadly similar to adults. Developing trust and being flexible are key skills that PC must use with AYAs. There is a paucity of high-quality controlled studies in the PC literature in general and AYA-PC in particular. Therefore, the methodology of this article is largely based on the narrative and clinical experience. The experience is based on clinicians' work with AYAs with cancer in Israel and Australia. Clinical lessons will be drawn by comparing and contrasting the cultures. Nevertheless, most PC clinical interventions, both pharmacologic and psychosocial, are derived from literature where there is a good evidence base. Future development of PC within AYAs should be coordinated at a national level via appropriate palliative and oncology professional organizations.