An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial

The benefits of early palliative care on psychological well-being, functional status, and health-related quality of life among cancer patients and their caregivers: a systematic review and meta-analysis

BACKGROUND

Patients with cancer and their caregivers experience significant psychological, physical, and emotional burdens throughout the disease trajectory which reduces their quality of life (QoL). Early palliative care (EPC) has been proposed as a strategy to alleviate physical, psychological and emotional burdens and improve health outcomes. While evidence generally supports the benefits of EPC, variations in reported outcomes highlight the need for a deeper understanding of its impact across different patient populations and healthcare settings.

OBJECTIVE

The primary aim of this study was to evaluate the pooled effects of EPC on psychological, functional status, and QoL outcomes in both cancer patients and their caregivers. The secondary aim was to evaluate the satisfaction of the patients and their family caregivers.

METHODS

A systematic review and meta-analysis were conducted following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Four databases, PubMed, Scopus, EBSCOhost, and Cochrane, were searched up to January 2024. This study included randomized controlled trial (RCT) and pilot-RCT studies reporting psychological outcomes (anxiety, depression), functional status, QoL, and satisfaction in cancer patients and their caregivers. Subgroup analysis was performed to explore the short-term (< 24 weeks) versus long-term (≥ 24 weeks) effects of EPC. Mean differences (MD) and standard mean differences (SMD) were calculated using a fixed-effects model according to the Mantel-Haenszel model and a random-effects model according to the DerSimonian and Laird method.

RESULTS

A total of 24 studies met our inclusion criteria. For cancer patients, EPC significantly reduced anxiety (MD = -0.62, 95% CI: -1.02; -0.23, p = 0.002) and improved QoL (SMD 0.13, 95%CI: 0.06; 0.19, p = 0.0004). However, there was no significant reduction in depression (SMD -0.15, 95% CI: -0.36; 0.05, p = 0.14) and improvement in functional status (MD = 2.14, 95% CI: -0.78; 5.06, p = 0.15). Subgroup analysis revealed that long-term EPC significantly reduced anxiety and depression while improving QoL, but had no significant effects on functional status. For caregivers, EPC did not significantly impact either physical or mental QoL (Short form/SF-36 physical: MD = 0.81, 95% CI: -0.46; 2.09, p = 0.21; SF-36 Mental: MD = 0.53, 95% CI: -1.03; 2.08, p = 0.51). Moreover, satisfaction was more likely to be higher in patients and their caregivers who received EPC than in those who received usual care (MD 2.45, 95% CI: 0.90; 4.01, p = 0.002, MD 4.09, 95% CI: 0.60; 7.58, p = 0.02, respectively).

CONCLUSION

EPC reduces long term psychological burden and improve QoL and care satisfaction experience among patients with cancer. Therefore, EPC should be more broadly introduced into cancer care earlier to address patient's psychological burdens.

Defining "early palliative care" for adults diagnosed with a life-limiting illness: a scoping review

BACKGROUND

Palliative care is for people suffering from life-limiting illnesses that focuses on providing relief from symptoms and stress of illness. Previous studies have demonstrated that specialist palliative care consultation delivered earlier in the disease process can enhance patients' quality of life, reduce their symptom burden, reduce use of hospital-based acute care services and extend their survival. However, various definitions exist for the term early palliative care (EPC).

OBJECTIVE

To investigate how EPC has been defined in the literature for adults with life- limiting illnesses.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews guidelines and follows the Joanna Briggs Institution methodology for scoping reviews. The literature search was conducted using MEDLINE (Ovid), CINAHL (EBSCO), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection, Ovid Cochrane Library, and ProQuest (Health and Medicine and Sociology Collections). All articles retrieved were screened by three independent reviewers.

RESULTS

153 articles met the inclusion criteria between 2008 and 2024. Five categories of definitions for EPC were created to organize definitions: (1) time-based (e.g. time from advanced cancer diagnosis to EPC initiation); (2) prognosis-based (e.g. prognosis or the 'surprise question'); (3) location-based (e.g. access point within the healthcare system such as outpatient setting); (4) treatment-based (e.g. physician's judgement or prior to specific therapies); and (5) symptom-based (e.g. using symptom intensity questionnaires). Many studies included patients with cancer (n = 103), with the most common definition category being time-based (n = 53). Amongst studies focusing on multiple or non-cancer diagnoses (n = 50), the most common definition category was symptom-based (n = 16).

CONCLUSION

Our findings provide a useful reference point for those seeking to understand the scope and breadth of existing EPC definitions in cancer and non-cancer illnesses and contemplate their application within clinical practice.

Algorithm-Based Palliative Care in Patients With Cancer: A Cluster Randomized Clinical Trial

Importance

Among patients with advanced solid malignant tumors, early specialty palliative care (PC) is guideline recommended, but strategies to increase PC access and effectiveness in community oncology are lacking.

Objective

To test whether algorithm-based defaults with opting out and accountable justification embedded in the electronic health record (EHR) increase completed PC visits.

Design, Setting, and Participants

This 2-arm cluster randomized clinical trial was conducted from November 1, 2022, to December 31, 2023. Eligible patients from 15 urban or rural clinics within a large community oncology network in Tennessee had advanced lung or noncolorectal gastrointestinal cancer and were identified by an automated EHR algorithm adapted from national guidelines. Data were analyzed between November 1, 2023, and March 4, 2024.

Intervention

At sites randomized to control, clinicians received weekly reports detailing PC referral rates compared with peer clinicians (peer comparison) and referred patients to PC at their discretion. At sites randomized to intervention, clinicians also received default PC orders using the EHR. Clinicians who opted out of PC consultation were asked to provide justification (accountable justification). If clinicians did not opt out, a study coordinator contacted patients to introduce and schedule PC visits using a standardized, predefined script.

Main Outcomes and Measures

The primary outcome was a completed PC consultation within 12 weeks of enrollment. Exploratory outcomes included quality of life, feeling heard and understood, and intensive end-of-life care. Outcomes were analyzed using clustered generalized linear and logistic regression models.

Results

The trial enrolled 562 patients (mean [SD] age, 68.5 [10.1] years; 288 male [51.2%]), of whom 433 (77.0%) had lung cancer. There were 130 of 296 patients (43.9%) randomized to the intervention group and 22 of 266 (8.3%) randomized to the control group who completed PC visits (adjusted odds ratio, 8.9 [95% CI, 5.5-14.6]; P < .001). Among 179 patients who died at the 24-week follow-up, 6 of 92 (6.5%) in the intervention group compared with 14 of 87 (16.1%) in the control group received systemic therapy within 14 days of death (adjusted odds ratio, 0.3 [95% CI, 0.1-0.7]; P = .05). There were no differences in quality of life, feeling heard and understood, or late hospice referral.

Conclusions and Relevance

In this randomized clinical trial of algorithm-based EHR defaults, the intervention increased PC consultations and decreased end-of-life systemic therapy. The intervention provides a scalable implementation strategy to increase specialty PC referrals in the community oncology setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT05590962.

Early, integrated palliative care for people with chronic respiratory disease: lessons learnt from lung cancer

Lung cancer and chronic non-malignant respiratory disease cause pervasive, multifactorial suffering for patients and informal carers alike. Palliative care aims to reduce suffering and improve quality of life for patients and their families. An established evidence base exists that has demonstrated the essential role of specialist palliative care for people with lung cancer. Emerging evidence supports similar benefits among people with chronic respiratory disease. Many lessons can be learnt from lung cancer care, particularly as the model of care delivery has transformed over recent decades due to major advances in the diagnostic pathway and the development of new treatments. This narrative review aims to summarize the evidence for specialist palliative care in lung cancer and chronic respiratory disease, by highlighting seven key lessons from lung cancer care that can inform the development of proactive, integrated models of palliative care among those with chronic respiratory disease. These seven lessons emphasize (1) managing challenging symptoms; (2) the efficacy of specialist palliative care; (3) the importance of providing specialist palliative care integrated with disease-directed care according to patients' needs not prognosis; (4) the need for new models of collaborative palliative care, (5) which are culturally appropriate and (6) able to evolve with changes in disease-directed care. Finally, we discuss (7) some of the critical research gaps that persist and reduce implementation in practice.

Quality versus risk of bias assessment of palliative care trials: comparison of two tools

BACKGROUND

Randomised controlled trials (RCTs) of palliative care interventions are challenging to conduct and evaluate. Tools used to judge the quality of RCTs do not account for the complexities of conducting research in seriously ill populations and may artificially downgrade confidence in palliative care research.

OBJECTIVE

To compare assessments from the Palliative Care Trial Assessment Tool (PCTAT) and Cochrane Risk of Bias (RoB) tool.

DESIGN

Reviewers assessed 43 RCTs using PCTAT and RoB. We compared assessments of each trial, assessed overall agreement (weighted kappa (Kw)) and examined (dis)agreement for comparable items. We assessed quality of life at 1-3 months among trials grouped according to RoB or PCTAT score (using meta-analysis) and whether RoB or quality improved over time (Cochran-Armitage trend test).

RESULTS

Of 43 trials, those rated low RoB had a mean PCTAT score of 73 (SD 10); those rated high RoB had a mean PCTAT score of 56 (SD 14). Overall Kw was 0.33 (95% CI 0.19 to 0.42). Total agreement between comparable items was observed for 56% of trials (24/43) and total disagreement for 21% (8/43). The standardised mean difference in quality of life was statistically significant among RCTs with low RoB and high PCTAT, but not for those with medium/low PCTAT or high/unclear RoB. Quality of reporting improved over time, whereas RoB did not.

CONCLUSION

Although there was fair agreement between tools, areas of disagreement/non-comparability suggest the tools capture different aspects of bias/quality. A specific tool to evaluate quality of palliative care trials may be warranted.

Palliative rehabilitation and quality of life: systematic review and meta-analysis

IMPORTANCE

International guidelines recommend the integration of multidisciplinary rehabilitation into palliative care services but its impact on quality of life across disease types is not well understood.

OBJECTIVE

To determine the effect of multidisciplinary palliative rehabilitation on quality of life and healthcare service outcomes for adults with an advanced, life-limiting illness.

DATA SOURCES

Electronic databases CINAHL, EMBASE, MEDLINE and PEDro were searched from the earliest records to February 2024.

STUDY SELECTION

Randomised controlled trials examining the effect of multidisciplinary palliative rehabilitation in adults with an advanced, life-limiting illness and reported quality of life were eligible.

DATA EXTRACTION AND SYNTHESIS

Study characteristics, quality of life and health service usage data were extracted, and the methodological quality was assessed using PEDro. Meta-analyses using random effects were completed, and Grades of Recommendation, Assessment, Development and Evaluation criteria were applied.

MAIN OUTCOMES

Quality of life and healthcare service outcomes.

RESULTS

27 randomised controlled trials (n=3571) were included. Palliative rehabilitation was associated with small improvements in quality of life (standardised mean difference (SMD) 0.40, 95% CI 0.23 to 0.56). These effects were significant across disease types: cancer (SMD 0.22, 95% CI 0.03 to 0.41), heart failure (SMD 0.37, 95% CI 0.61 to 0.05) and non-malignant respiratory diagnoses (SMD 0.77, 95% CI 0.29 to 1.24). Meta-analysis found low-certainty evidence, palliative rehabilitation reduced the length of stay by 1.84 readmission days.

CONCLUSIONS AND RELEVANCE

Multidisciplinary palliative rehabilitation improves quality of life for adults with an advanced, life-limiting illness and can reduce time spent in hospital without costing more than usual care. Palliative rehabilitation should be incorporated into standard palliative care.

PROSPERO REGISTRATION NUMBER

CRD42022372951.

Meta-analysis on Effectiveness of Palliative Care versus Conventional Care amongst Advanced Gynaecological Patients with Cancer and Caregivers

In cancer patients, physical and psychological issues are very common. There is a need for family support and high utilisation of healthcare resources commonly. Palliative care (PC) has grown in popularity to better fulfil of needs of patients and their families and potentially lowering hospital costs. Given that the majority of patients still die in hospitals, there is a need for an effective model of PC for advanced gynaecological cancer, as well as the wise allocation of scarce resources. The main aim of this study was to compare the efficacy of PC to conventional treatment for adults with cancer, including gynaecological cancers, and their caregivers. Four randomised controlled trials (RCTs) were identified by searching PubMed, PubMed Central, Clinical Key, Embase and other grey literature from a duration of 2011-2021. Cochrane criteria were used to calculate the risk of bias, and the Grade Profiler Guideline Development Tool was used to check the quality of the included studies. Standardised mean differences (SMDs), I2 value and forest plot were prepared by using Review Manager 4.0. A total of four RCTs were extracted by following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and found to have a high risk for bias and low to poor quality of evidence. Included study sample sizes ranged from 22 to 104 participants, including 670 people in total, including 289 patients with advanced cancer patients, including gynaecological cancer and 381 unpaid caregivers. Results also showed that PC enhances patients' quality of life (SMD = 0.26; 95% confidence interval [CI] = -0.29-0.80; I2 = 76%), lowered symptom burden amongst patients (SMD = -0.75, 95% CI = -1.75-0.25; I2 = 89%), reduces patient depression (SMD = 0.08, 95% CI = -0.19-0.34; I2 = 0%) and decreases depression in unpaid caregivers (SMD = -0.16, 95% CI = -0.56-0.24; I2 = 59%). PC treatment increases patients' quality of life and lowers their symptom burden. In comparison to conventional care, it also reduces depression among patients and caregivers. We believe that the findings should be viewed with care until more recent exclusive RCTs are available.

Palliative care case management in a surgical department for patients with gastrointestinal cancer-a register-based cohort study

BACKGROUND

The effectiveness of generalist palliative care interventions in hospitals is unknown.

AIM

This study aimed to explore the impact of a palliative care case management intervention for patients with gastrointestinal cancer (PalMaGiC) on hospital admissions, healthcare use, and place of death.

DESIGN

This was a register-based cohort study analyzing data from the Danish Register on Causes of Death, the Danish National Patient Register, and the Danish Palliative Database.

SETTING/PARTICIPANTS

Deceased patients with gastrointestinal cancer from 2010 to 2020 exposed to PalMaGiC were compared over three periods of time to patients receiving standard care.

RESULTS

A total of 43,969 patients with gastrointestinal cancers were included in the study, of whom 1518 were exposed to PalMaGiC. In the last 30 days of life, exposed patients were significantly more likely to be hospitalized (OR of 1.62 (95% CI 1.26-2.01)), spend more days at the hospital, estimate of 1.21 (95% CI 1.02-1.44), and have a higher number of hospital admissions (RR of 1.13 (95% CI 1.01-1.27)), and were more likely to die at the hospital (OR of 1.94 (95% CI 1.55-2.44)) with an increasing trend over time. No differences were found for hospital healthcare use.

CONCLUSION

Patients exposed to the PalMaGiC intervention had a greater likelihood of hospitalizations and death at the hospital compared to unexposed patients, despite the opposite intention. Sensitivity analyses show that regional differences may hold some of the explanation for this. Future development of generalist palliative care in hospitals should focus on integrating a home-based approach, community care, and PC physician involvement.

Early Integrated Palliative Care in Patients With Advanced Cancer: A Randomized Clinical Trial

Importance

Limited data suggest that early palliative care (EPC) improves quality of life (QOL) and survival in patients with advanced cancer.

Objective

To evaluate whether comprehensive EPC improves QOL; relieves mental, social, and existential burdens; increases survival rates; and helps patients develop coping skills.

Design, Setting, and Participants

This nonblinded randomized clinical trial (RCT) recruited patients from 12 hospitals in South Korea from September 2017 to October 2018. Patients aged 20 years or older with advanced cancer who were not terminally ill but for whom standard chemotherapy has not been effective were eligible. Participants were randomized 1:1 to the control (receiving usual supportive oncological care) or intervention (receiving EPC with usual oncological care) group. Intention-to-treat data analysis was conducted between September and December 2022.

Interventions

The intervention group received EPC through a structured program of self-study education materials, telephone coaching, and regular assessments by an integrated palliative care team.

Main Outcomes and Measures

The primary outcome was the change in overall QOL score (assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care) from baseline to 24 weeks after enrollment, with evaluations also conducted at 12 and 18 weeks. Secondary outcomes were social and existential burdens (assessed with the McGill Quality of Life Questionnaire) as well as crisis-overcoming capacity and 2-year survival.

Results

A total of 144 patients (83 males [57.6%]; mean [SD] age, 60.7 (7.2) years) were enrolled, of whom 73 were randomized to the intervention group and 71 to the control group. The intervention group demonstrated significantly greater changes in scores in overall health status or QOL from baseline, especially at 18 weeks (11.00 [95% CI, 0.78-21.22] points; P = .04; effect size = 0.42). However, at 12 and 24 weeks, there were no significant differences observed. Compared with the control group, the intervention group also showed significant improvement in self-management or coping skills over 24 weeks (20.51 [95% CI, 12.41-28.61] points; P < .001; effect size = 0.93). While the overall survival rate was higher in the intervention vs control group, the difference was not significant. In the intervention group, however, those who received 10 or more EPC interventions (eg, telephone coaching sessions and care team meetings) showed a significantly increased probability of 2-year survival (53.6%; P < .001).

Conclusions and Relevance

This RCT demonstrated that EPC enhanced QOL at 18 weeks; however, no significant improvements were observed at 12 and 24 weeks. An increased number of interventions sessions was associated with increased 2-year survival rates in the intervention group.

Trial Registration

ClinicalTrials.gov Identifier: NCT03181854.

Palliative Care for Patients With Cancer: ASCO Guideline Update

PURPOSE

To provide evidence-based guidance to oncology clinicians, patients, nonprofessional caregivers, and palliative care clinicians to update the 2016 ASCO guideline on the integration of palliative care into standard oncology for all patients diagnosed with cancer.

METHODS

ASCO convened an Expert Panel of medical, radiation, hematology-oncology, oncology nursing, palliative care, social work, ethics, advocacy, and psycho-oncology experts. The Panel conducted a literature search, including systematic reviews, meta-analyses, and randomized controlled trials published from 2015-2023. Outcomes of interest included quality of life (QOL), patient satisfaction, physical and psychological symptoms, survival, and caregiver burden. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 52 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Evidence-based recommendations address the integration of palliative care in oncology. Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer. For patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services complementing existing or emerging supportive care interventions. Oncology clinicians from across the interdisciplinary cancer care team may refer the caregivers (eg, family, chosen family, and friends) of patients with cancer to palliative care teams for additional support. The Expert Panel suggests early palliative care involvement, especially for patients with uncontrolled symptoms and QOL concerns. Clinicians caring for patients with solid tumors on phase I cancer trials may also refer them to specialist palliative care.Additional information is available at www.asco.org/supportive-care-guidelines.

Uncertainty among patients with advanced-stage lung cancer

BACKGROUND

Uncertainty is the inability to define the meaning of illness-related events, which may result in anxiety, depression, poor coping, the self-perception of being a burden and low quality of life. Uncertainty among Thai patients with advanced-stage lung cancer (ASLC) has not been well documented.

AIMS

To assess uncertainty in patients with ASLC.

METHODS

A cross-sectional survey design was adopted. Data were collected from 60 patients with ASLC at a university hospital. A demographic data form and the Mishel Uncertainty in Illness Scale (MUIS) were used to collect data. The data were analysed using descriptive statistics.

RESULTS

The patients had moderate levels of uncertainty in illness (83.73±15.25). Ambiguity about the illness and unpredictability of the prognosis scored at a moderate level for patients, while complexity of treatment and the system of care and inconsistency or lack of information, about the diagnosis or severity of the illness were at a low level.

CONCLUSION

The results of this study may help healthcare professionals better understand and manage uncertainty in patients with ASLC.

Advancing Palliative Care through Advanced Nursing Practice: A Rapid Review

Objectives

This study addresses the growing demand for palliative care (PC) by exploring the role of advanced nursing practice (ANP) within the multidisciplinary team. The purpose is to outline the background of ANP in PC, its interest, training needs, and some recommendations for its establishment in the Moroccan healthcare system.

Materials and Methods

A rapid review of relevant studies was carried out through databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards, edition (2020). The inclusion criteria focussed on studies published within the nursing domain between 2012 and 2022, with a preference for the English language.

Results

Study selection allowed to obtain eight relevant studies. The studies agreed that ANP improves the quality of care provided. It has a major role to play in the multidisciplinary team by mobilising all the knowledge required to offer a complete range of care for patients with needs. Nevertheless, its implementation is fraught with challenges.

Conclusion

ANP will be able to address the complexity of patient and family needs and serve as cost-effective medical care coordinators for patients and families with both chronic and life-limiting illnesses, to reduce suffering and improve the quality of living and dying across the lifespan. Advanced practice nurses execute assigned authorisations by mobilising the knowledge acquired through university training. The establishment of this cadre in the healthcare system is subject to many challenges that Morocco must anticipate.

PALLiative care in ONcology (PALLiON): A cluster-randomised trial investigating the effect of palliative care on the use of anticancer treatment at the end of life

BACKGROUND

Effects on anticancer therapy following the integration of palliative care and oncology are rarely investigated. Thus, its potential effect is unknown.

AIM

To investigate the effects of the complex intervention PALLiON versus usual care on end-of-life anticancer therapy.

DESIGN

Cluster-randomised controlled trial (RCT), registered at ClinicalTrials.gov (No. NCT03088202). The complex intervention consisted of a physician education program enhancing theoretical, clinical and communication skills, a patient-centred care pathway and patient symptom reporting prior to all consultations. Primary outcome was overall use, start and cessation of anticancer therapy in the last 3 months before death. Secondary outcomes were patient-reported outcomes. Mixed effects logistic regression models and Cox proportional hazard were used.

SETTING

A total of 12 Norwegian hospitals (03/2017-02/2021).

PARTICIPANTS

Patients ⩾18 years, advanced stage solid tumour, starting last line of anticancer therapy, estimated life expectancy ⩽12 months.

RESULTS

A total of 616 (93%) patients were included (intervention: 309/control:307); 63% males, median age 69, 77% had gastrointestinal cancers. Median survival time from inclusion was 8 (IQR 3-14) and 7 months (IQR 3-12), and days between anticancer therapy start and death were 204 (90-378) and 168 (69-351) (intervention/control). Overall, 78 patients (13%) received anticancer therapy in the last month (intervention: 33 [11%]/control: 45 [15%]). No differences were found in patient-reported outcomes.

CONCLUSION

We found no significant differences in the probability of receiving end-of-life anticancer therapy. The intervention did not have the desired effect. It was probably too general and too focussed on communication skills to exert a substantial influence on conventional clinical practice.

Thirteen Nonpharmacological Interventions for Increasing the Quality of Life in Patients with Advanced Cancer: A Network Meta-analysis

BACKGROUND

A variety of nonpharmacological interventions that improve the quality of life of patients with advanced cancer have been difficult for medical staff to select through randomized controlled trials or traditional meta-analyses. Thus, a network meta-analysis is necessary.

OBJECTIVE

This study used network meta-analysis to analyze the effect of 13 different nonpharmacological interventions on improving the living quality of patients with advanced cancer.

METHODS

Five English databases were searched up to January 2019. The search strategy only included terms relating to or describing the intervention.

RESULTS

The study included 13 different nonpharmacological interventions. The overall efficacy was summarized through a holistic study of quality of life. The study found that the combined effect sizes of 13 nonpharmacological interventions crossed the invalid line (weighted mean difference, -13 [95% confidence interval, -33 to 8.5] to 1.7 [95% confidence interval, -18 to 22]), indicating that none of the intervention was significantly different from each other. By evaluating the heterogeneity of this outcome, no significant evidence of heterogeneity ( P > .05) was observed. Probability ranking according to the surface under the cumulative ranking curve showed that there was a great possibility for the CanWalk intervention and structured multidisciplinary intervention to improve outcomes for cancer patients.

CONCLUSIONS

Thirteen nonpharmacological interventions did not significantly impact quality of life. Regarding the probability rank, CanWalk intervention may be the most promising way that advanced cancer patients can help themselves to a better life. Because of the limitations of the current studies, the conclusion needs further evidence.

IMPLICATIONS FOR PRACTICE

Nurses should consider recommending moderate physical activity for patients with advanced cancer.

Palliative care interventions for patients with head and neck cancer: protocol for a scoping review

INTRODUCTION

A head and neck cancer (HNC) diagnosis significantly impacts a patient's quality of life (QOL). Palliative care potentially improves their QOL. We will conduct a scoping review to identify existing knowledge about palliative care interventions for patients with HNC.

METHODS AND ANALYSIS

This scoping review was designed in accordance with the JBI Manual for Evidence Synthesis: Scoping Reviews and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Our eligibility criteria follow the Population, Intervention, Comparison or Control, Outcomes and Study characteristics framework. The population is adult patients with locally advanced, metastatic, unresectable and/or recurrent HNC. We include peer-reviewed journal articles and articles in the press, in English, reporting on palliative care interventions with at least two of the eight National Consensus Project on Clinical Practice Guidelines for Quality Palliative Care domains; studies with and without comparators will be included. The outcomes are patient QOL (primary) and symptom severity, patients' satisfaction with care, patients' mood, advance care planning and place of death (secondary). We developed a search strategy across ten databases, to be searched from the inception to 11 September 2023: Medline ALL (Medline and EPub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase Classic+Embase, Emcare and PsycINFO all from the OvidSP platform; CINAHL from EBSCOhost, Scopus from Elsevier, Web of Science from Clarivate and Global Index Medicus from WHO. We will extract data using a piloted data form and analyse the data through descriptive statistics and thematic analysis.

ETHICS AND DISSEMINATION

Ethics approval is not needed for a scoping review. We will disseminate the findings to healthcare providers and policy-makers by publishing the results in a scientific journal.

Meta-Analysis of Effects of Early Palliative Care on Health-Related Outcomes Among Advanced Cancer Patients

BACKGROUND

Early palliative care (PC) has received more attention for improving health-related outcomes for advanced cancer patients in recent years, but the results of previous studies are inconsistent.

OBJECTIVES

This study aimed to use meta-analysis and trial sequence analysis to evaluate the effect of early PC on health-related outcomes of advanced cancer patients.

METHODS

All English publications were searched in PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 2023, with a restriction that the study type was a randomized controlled trial.

RESULTS

The results showed that early PC positively affected quality of life, satisfaction with care, and symptom burden reduction. However, early PC had no significant effect on anxiety or survival. Trial sequence analysis results showed that the effect of early PC on the quality of life was stable.

DISCUSSION

This systematic review suggested that early PC could positively affect health-related outcomes for advanced cancer patients. Early PC can be used widely in clinical settings to improve health-related outcomes of advanced cancer. However, because of the trial sequence analysis results, further well-designed, clinical, randomized controlled trials with larger sample sizes are necessary to draw definitive conclusions.

Integrating palliative care into the evolving landscape of oncology

Patients with cancer have many palliative care needs. Robust evidence supports the early integration of palliative care into the care of patients with advanced cancer. International organizations, such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), have recommended early, longitudinal integration of palliative care into oncology care throughout the cancer trajectory. In this review, we pose a series of clinical questions related to the current state of early palliative care integration into oncology. We review the evidence to address each of these questions and highlight areas for further investigation. As cancer care continues to evolve, incorporating new treatment modalities and improving patient outcomes, we reflect on how to apply the existing evidence supporting early palliative care-oncology integration into this ever-changing therapeutic landscape and how specialty palliative care might adapt to meet the evolving needs of patients, caregivers, and the multidisciplinary oncology team.

What Nursing-Sensitive Outcomes Have Been Investigated to Date among Patients with Solid and Hematological Malignancies? A Scoping Review

Nursing-sensitive outcomes are those outcomes attributable to nursing care. To date three main reviews have summarized the evidence available regarding the nursing outcomes in onco-haematological care. Updating the existing reviews was the main intent of this study; specifically, the aim was to map the state of the art of the science in the field of oncology nursing-sensitive outcomes and to summarise outcomes and metrics documented as being influenced by nursing care. A scoping review was conducted in 2021. The MEDLINE, Cumulative Index to Nursing and Allied Health, Web of Science, and Scopus databases were examined. Qualitative and quantitative primary and secondary studies concerning patients with solid/haematological malignancies, cared for in any setting, published in English, and from any time were all included. Both inductive and deductive approaches were used to analyse the data extracted from the studies. Sixty studies have been included, mostly primary (n = 57, 95.0%) with a quasi- or experimental approach (n = 26, 55.3%), conducted among Europe (n = 27, 45.0%), in hospitals and clinical wards (n = 29, 48.3%), and including from 8 to 4615 patients. In the inductive analysis, there emerged 151 outcomes grouped into 38 categories, with the top category being 'Satisfaction and perception of nursing care received' (n = 32, 21.2%). Outcome measurement systems included mainly self-report questionnaires (n = 89, 66.9%). In the deductive analysis, according to the Oncology Nursing Society 2004 classification, the 'Symptom control and management' domain was the most investigated (n = 44, 29.1%); however, the majority (n = 50, 33.1%) of nursing-sensitive outcomes that emerged were not includible in the available framework. Continuing to map nursing outcomes may be useful for clinicians, managers, educators, and researchers in establishing the endpoints of their practice. The ample number of instruments and metrics that emerged suggests the need for more development of homogeneous assessment systems allowing comparison across health issues, settings, and countries.

Palliative Care Interventions Effects on Psychological Distress: A Systematic Review & Meta-Analysis

BACKGROUND

Managing psychological distress is an objective of palliative care. No meta-analysis has evaluated whether palliative care reduces psychological distress.

OBJECTIVES

Examine the effects of palliative care on depression, anxiety, and general psychological distress for adults with life-limiting illnesses and their caregivers.

DESIGN

We searched PubMed, PsycInfo, Embase, and CINAHL for randomized clinical trials (RCTs) of palliative care interventions. RCTs were included if they enrolled adults with life-limiting illnesses or their caregivers, reported data on psychological distress at 3 months after study intake, and if authors had described the intervention as "palliative care."

RESULTS

We identified 38 RCTs meeting our inclusion criteria. Many (14/38) included studies excluded participants with common mental health conditions. There were no statistically significant improvements in patient or caregiver anxiety (patient SMD: -0.008, P = 0.96; caregiver SMD: -0.21, P = 0.79), depression (patient SMD: -0.13, P = 0.25; caregiver SMD -0.27, P = 0.08), or psychological distress (patient SMD: 0.26, P = 0.59; caregiver SMD: 0.04, P = 0.78).

CONCLUSIONS

Psychological distress is not likely to be reduced in the context of a typical palliative care intervention. The systemic exclusion of patients with common mental health conditions in more than 1/3 of the studies raises ethical questions about the goals of palliative care RCTS and could perpetuate inequalities.

Use and impact of a novel nurse-led consultation model in a palliative care consultation service for terminally ill cancer patients in Taiwan: an 11-year observational study

PURPOSE

The early integration of palliative care for terminally ill cancer patients improves quality of life. We have developed a new nurse-led consultation model for use in a palliative care consultation service (PCCS) to initiate early palliative care for cancer patients.

METHODS

In this 11-year observational study, data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill cancer patients who had received PCCS during the years 2011 to 2021 were enrolled. Trend analysis was performed in order to evaluate differences in outcomes seen within the categories of either a nurse-led consultation model or ordinary consultation model throughout the study period. Analysis included studying the duration of PCCS and DNR declaration, as well as awareness of disease by both patients and families before and after PCCS.

RESULTS

In total, 6923 cancer patients with an average age of 64.1 years received PCCS from 2011 to 2021, with the average duration of PCCS being 11.1 days. Three thousand four hundred twenty-one patients (49.4%) received both a nurse consultation and doctor consultation during PCCS. Being admitted to the Department of Hematology, a longer duration of hospitalization, a DNR declaration after PCCS, and having had a PCCS consultation by a nurse only or both with a nurse and a doctor were significant determinants of a PCCS duration of more than 7 days.

CONCLUSION

This 11-year observational study shows that the number of terminal cancer patients receiving a novel nurse-led consultation during PCCS has increased significantly during the past decade, while a nurse-led consultation model during PCCS was effective in improving the duration of PCCS among terminally ill cancer patients.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol

INTRODUCTION

Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources.

SETTING

Selected oncology clinics and PC outpatient clinic.

METHODS AND ANALYSIS

A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04936568.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Impact of palliative care on quality of life in advanced cancer: A meta-analysis of randomised controlled trials

INTRODUCTION

This study aimed to examine the impact of palliative care on the life quality of adults with advanced cancer.

METHODS

After a comprehensive and regular search using [MeSH] keywords in some important databases, 25 published randomised controlled trials (RCTs) involving 5160 adults with advanced cancer were selected and examined through meta-analysis.

RESULTS

Analysis of 36 reports in 1-3 months follow-up, and 19 reports in 4-7 months follow-up, showed that compared to usual care (g = 0.25; 95%CI: 0.1 to 0.41), palliative care had a significant impact on quality of life (QOL) (g = 0.1; 95%CI: 0.019 to 0.18) of advanced cancer patients. Also, based on the analysis of 15 reports on outpatients (g = 0.27; 95%CI: 0.04 to 0.4), 10 reports of early (g = 0.27; 95%CI: 0.029 to 0.52), and 8 reports of end-of-life (g = 0.24; 95%CI: 0.06 to 0.47) palliative care in 4-7 months follow-up, a significant impact on life quality was shown. However, in four reports, the impact of palliative care on health related quality of life in ≥10 months follow-up (g = 0.19; 95%CI: -0.03 to 0.42) was not significant.

CONCLUSION

Systematic QOL assessment with valid tool in palliative care setting would establish quality assurance and could further develop the application of this pretty new discipline in oncology care worldwide.

Efficacy of models of palliative care delivered beyond the traditional physician-led, subspecialty consultation service model: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to determine the effectiveness of non-physician provider-led palliative care (PC) interventions in the management of adults with advanced illnesses on patient-reported outcomes and advance care planning (ACP).

METHODS

We included randomised trials and cluster trials published in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Register of Controlled Trials and ClinicalTrials.gov searched until July 2021 that examined individuals ≥18 years with a diagnosis of advanced, life-limiting illness and received a PC intervention led by a non-physician (nurse, advance practitioner or social worker). Our primary outcome was quality of life (QOL), which was extracted as unadjusted or adjusted estimates and measures of variability. Secondary outcomes included anxiety, depression and ACP.

RESULTS

Among the 21 studies (2370 subjects), 13 included patients with cancer, 3 with heart failure, 4 with chronic respiratory disease and 1 with chronic kidney disease. The interventions were diverse and varied with respect to team composition and services offered. For QOL, the standardised mean differences suggested null effects of PC interventions compared with usual care at 1-2 months (0.04; 95% CI=-0.14 to 0.23, n=10 randomised controlled trials (RCTs)) and 6-7 months (0.10; 95% CI=-0.15 to 0.34, n=6 RCTs). The results for anxiety and depression were not significant also. For the ACP, there was a strong benefit for the PC intervention (absolute increase of 0.32% (95% CI=0.06 to 0.57).

CONCLUSIONS

In this meta-analysis, PC interventions delivered by non-physician were not associated with improvement in QOL, anxiety or depression but demonstrated an impact on the ACP discussion and documentation.

Effects of an Oncology Nurse-Led, Primary Palliative Care Intervention (CONNECT) on Illness Expectations Among Patients With Advanced Cancer

PURPOSE

Patients with advanced cancer often have unrealistic expectations about prognosis and treatment. This study assessed the effect of an oncology nurse-led primary palliative care intervention on illness expectations among patients with advanced cancer.

METHODS

This study is a secondary analysis of a cluster-randomized trial of primary palliative care conducted at 17 oncology clinics. Adult patients with advanced solid tumors for whom the oncologist would not be surprised if died within 1 year were enrolled. Monthly visits were designed to foster realistic illness expectations by eliciting patient concerns and goals for their medical care and empowering patients and families to engage in discussions with oncologists about treatment options and preferences. Baseline and 3-month questionnaires included questions about life expectancy, treatment intent, and terminal illness acknowledgment. Odds of realistic illness expectations at 3 months were adjusted for baseline responses, patient demographic and clinical characteristics, and intervention dose.

RESULTS

Among 457 primarily White patients, there was little difference in realistic illness expectations at 3 months between intervention and standard care groups: 12.8% v 11.4% for life expectancy (adjusted odds ratio [aOR] = 1.15; 95% CI, 0.59 to 2.22; P = .684); 24.6% v 33.3% for treatment intent (aOR = 0.76; 95% CI, 0.44 to 1.27; P = .290); 53.6% v 44.7% for terminal illness acknowledgment (aOR = 1.28; 95% CI, 0.81 to 2.00; P = .288). Results did not differ when accounting for variation in clinic sites or intervention dose.

CONCLUSION

Illness expectations are difficult to change among patients with advanced cancer. Additional work is needed to identify approaches within oncology practices that foster realistic illness expectations to improve patient decision making.

Effects of Early Palliative Care in Advanced Cancer Patients: A Meta-Analysis

Objective: Advanced cancer patients often suffer from a reduced quality of life (QoL) and cancer-related symptoms. Early palliative care may improve their QoL and symptom severity. Methods: We conducted a meta-analysis of the effects of early palliative care on QoL, symptom severity, and other outcomes in advanced cancer patients, and searched PubMed, Embase, CINAHL, MEDLINE, and the Cochrane Library databases for potential randomized controlled trials (RCTs). The primary outcome was QoL. The secondary outcomes were symptom intensity and functional well-being (Trial Outcome Index, TOI). The study protocol has been registered and approved by PROSPERO (CRD42020164047). Results: We obtained 12 RCTs enrolling 2980 participants. Compared with the usual care, early palliative care significantly improved QoL at ≤ 3 months (SMD = .16, 95% CI = .05-.27) and when treated more 3 months (SMD = .26, 95% CI = .11-.40). Compared with usual treatment, patients who received early palliative care exhibited a significant reduction in symptom intensity when treated more than 3 months (SMD = .18, 95% CI = .06-.31) and in TOI ≤ 3 months (SMD = .28, 95% CI = .11-.45). Conclusions: Early palliative care improves QoL, symptom intensity, and TOI in advanced cancer patients. We recommend introducing early palliative care for advanced cancer patients as the approach provides additional clinical benefits compared with usual care.

Timely Palliative Care: Personalizing the Process of Referral

Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.

Benefits of Study Participation for Patients with Advanced Cancer Receiving Radiotherapy: A Prospective Observational Study

Background

Patients with advanced cancer and bone metastases may have unmet palliative care (PC) needs that go unnoticed during clinical oncological practice. This observational study describes interventions that were initiated as the patients participated in the Palliative Radiotherapy and Inflammation Study (PRAIS). It was hypothesized that the patients would benefit from study participation due to PC interventions initiated by the study team.

Methods

A retrospective review of patients' electronic records. Patients with advanced cancer and painful bone metastases included in PRAIS were eligible. All patients met with the study team before start of radiotherapy, after completion of Patient Reported Outcome Measures. Interventions initiated by the study team were documented in the patients' electronic records.

Results

A total of 133 patients were reviewed: 63% males, mean (standard deviation [SD]) age 65 (9.6) and mean (SD) Karnofsky performance status (KPS) score 73.2 (9.1). Interventions were initiated in 50% (n = 67) of the patients. Changes in opioid management (69%), treatment of constipation (43%), and nausea (24%) and nutritional advice were most frequent (21%). Patients receiving interventions had lower mean KPS (70 vs. 77 p < 0.001), shorter survival time after study inclusion (median 28 vs. 57.5 weeks p = 0.005) and were more often opioid naïve (12% vs. 39% p < 0.001) than those not receiving interventions by the study team.

Conclusions

Patients with advanced cancer and painful bone metastasis benefited from study participation due to multiple PC interventions initiated by the study team. The findings call for a systematic integration of PC in patients with advanced cancer.

Trial Registration

ClinicalTrials.gov NCT02107664.

A Study of Advanced Practice Provider Staffing Models and Professional Development Opportunities at National Comprehensive Cancer Network Member Institutions

Introduction

The National Comprehensive Cancer Network (NCCN) Best Practices Committee created an Advanced Practice Provider (APP) Workgroup to develop recommendations to support APP roles at NCCN Member Institutions.

Methods

The Workgroup conducted three surveys to understand APP program structure, staffing models, and professional development opportunities at NCCN Member Institutions.

Results

The total number of new and follow-up visits a 1.0 APP full-time equivalent conducts per week in shared and independent visits ranged from 11 to 97, with an average of 40 visits per week (n = 39). The type of visits APPs conduct include follow-up shared (47.2%), follow-up independent (46%), new shared (6.5%), and new independent visits (0.5%). Seventy-two percent of respondents utilize a mixed model visit type, with 15% utilizing only independent visits and 13% utilizing only shared visits (n = 39). Of the 95% of centers with APP leads, 100% indicated that leads carry administrative and clinical responsibilities (n = 20); however, results varied with respect to how this time is allocated. Professional development opportunities offered included posters, papers, and presentations (84%), leadership development (57%), research opportunities (52%), writing book chapters (19%), and other professional development activities (12%; n = 422). Twenty percent of APPs indicated that protected time to engage in development opportunities should be offered.

Conclusion

As evidenced by the variability of the survey results, the field would benefit from developing standards for APPs. There is a lack of information regarding leadership structures to help support APPs, and additional research is needed. Additionally, centers should continuously assess the career-long opportunities needed to maximize the value of oncology APPs.

Effect of Early Palliative Care on Quality of Life of Advanced Head and Neck Cancer Patients: A Phase III Trial

BACKGROUND

Early palliative care (EPC) is an important aspect of cancer management but, to our knowledge, has never been evaluated in patients with head and neck cancer. Hence, we performed this study to determine whether the addition of EPC to standard therapy leads to an improvement in the quality of life (QOL), decrease in symptom burden, and improvement in overall survival.

METHODS

Adult patients with squamous cell carcinoma of the head and neck region planned for palliative systemic therapy were allocated 1:1 to either standard systemic therapy without or with comprehensive EPC service referral. Patients were administered the revised Edmonton Symptom Assessment Scale and the Functional Assessment of Cancer Therapy for head and neck cancer (FACT-H&N) questionnaire at baseline and every 1 month thereafter for 3 months. The primary endpoint was a change in the QOL measured at 3 months after random assignment. All statistical tests were 2-sided.

RESULTS

Ninety patients were randomly assigned to each arm. There was no statistical difference in the change in the FACT-H&N total score (P = .94), FACT-H&N Trial Outcome Index (P = .95), FACT-general total (P = .84), and Edmonton Symptom Assessment Scale scores at 3 months between the 2 arms. The median overall survival was similar between the 2 arms (hazard ratio for death = 1.01, 95% confidence interval = 0.74 to 1.35). There were 5 in-hospital deaths in both arms (5.6% for both, P = .99).

CONCLUSIONS

In this phase III study, the integration of EPC in head and neck cancer patients did not lead to an improvement in the QOL or survival.

Early, integrated palliative rehabilitation improves quality of life of patients with newly diagnosed advanced cancer: The Pal-Rehab randomized controlled trial

BACKGROUND

Early integration of palliative care into oncology treatment is widely recommended. Palliative rehabilitation has been suggested as a paradigm which integrates enablement, self-management, and self-care into the holistic model of palliative care.

AIM

We hypothesized that early integration of palliative rehabilitation could improve quality of life.

DESIGN

The Pal-Rehab study (ClinicalTrials.gov NCT02332317) was a randomized controlled trial. The 12-week intervention offered by a specialized palliative care team was two mandatory consultations and the opportunity of participating in an interdisciplinary group program. Supplementary individual consultations were offered, if needed.

SETTING/PARTICIPANTS

At Vejle University Hospital, Denmark, adults diagnosed with advanced cancer within the last 8 weeks were randomized 1:1 to standard oncology care or standard care plus intervention. Assessments at baseline and after six and 12 weeks were based on the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30). At baseline participants were asked to choose a "primary problem" from a list of QLQ-C30 domains. The primary endpoint was the change in that "primary problem" measured as area under the curve across 12 weeks (T-scores, European mean value = 50, SD = 10).

RESULTS

In all, 288 were randomized of whom 279 were included in the modified intention-to-treat analysis (146 in the standard care group and 133 in the intervention group). The between-group difference for the primary outcome was 3.0 (95% CI [0.0-6.0]; p = 0.047) favoring the intervention.

CONCLUSION

Early integration of palliative rehabilitation into standard oncology treatment improved quality of life for newly diagnosed advanced cancer patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02332317, registered on December 30, 2014.

Preparing Oncology Advanced Practice RNs as Generalists in Palliative Care

OBJECTIVES

To train and support oncology advanced practice RNs (APRNs) to become generalist providers of palliative care.

SAMPLE & SETTING

APRNs with master's or doctor of nursing practice degrees and at least five years of experience in oncology (N = 165) attended a National Cancer Institute-funded national training course and participated in ongoing support and education.

METHODS & VARIABLES

Course participants completed a precourse, postcourse, and six-month follow-up evaluation regarding palliative care practices in their settings, course evaluation, and their perceived effectiveness in applying course content in their practice.

RESULTS

The precourse results showed deficiencies in current practice, with a low percentage of patients having palliative care as part of their oncology care. Barriers included lack of triggers that could assist in identifying patients who could benefit from palliative care. Six-month postcourse data showed more APRNs participating in family meetings, recommending palliative care consultations, speaking with family members regarding bereavement services, and preparing clinical staff for impending patient deaths.

IMPLICATIONS FOR NURSING

APRNs require palliative care training to integrate this care within their role. APRNs can influence practice change and improve care for patients in their settings.

Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review

Background

Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.

Objectives

The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.

Population

Adult patients with advanced illnesses and their unpaid caregivers.

Intervention

Hospital-based specialist palliative care.

Comparators

Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).

Primary outcomes

Patient health-related quality of life and symptom burden.

Data sources

Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.

Review methods

Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.

Results

Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I 2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I 2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I 2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I 2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I 2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I 2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I 2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.

Limitation

In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.

Conclusions

Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.

Future work

More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.

Study registration

This study is registered as PROSPERO CRD42017083205.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.

Models of Integration of Specialized Palliative Care with Oncology

OPINION STATEMENT

Evidence from randomized controlled trials and meta-analyses has shown that early integration of specialized palliative care improves symptoms and quality of life for patients with advanced cancer. There are various models of early integration, which may be classified based on setting of care and method of palliative care referral. Most successful randomized controlled trials of early palliative care have used a model of specialized teams providing in-person palliative care in free-standing or embedded outpatient clinics. During the COVID-19 pandemic, telehealth has become a prominent model for palliative care delivery. This model of care has been well received by patients and palliative care providers, although evidence to date is limited. Despite evidence from trials that routine early integration of palliative care into oncology care improves patient outcomes, referral to palliative care still occurs mostly according to the judgment of individual oncologists. This hinders equitable access to palliative care and to its known benefits for patients and their caregivers. Automated referral based on triggering criteria is being actively explored as an alternative. In particular, routine technology-assisted symptom screening, combined with targeted needs-based automatic referral to outpatient palliative care, may improve integration and ultimately increase quality of life.

Psychoeducational Nursing Intervention for Symptom Management in Cancer Patients: A Randomized Clinical Trial

Objective

The objective of this study was to assess the effects of a psychoeducational intervention upon symptom control and quality of life (QoL) among cancer patients.

Methods

This was an open randomized clinical trial (RCT) conducted at the Cancer Institute of the State of São Paulo. The RCT comprised 107 outpatients in chemotherapy or radiation for malignant neoplasms. Participants were randomized to control group (usual treatment) or intervention group (IG) (psychoeducational intervention) with assessments at baseline and upon completion of the intervention. Sociodemographic information, clinical data, QoL, functionality, and symptoms were assessed. This trial is registered with the Brazilian Clinical Trials Registry number RBR-9337nv. A mixed-effects model was applied to compare the effects of the intervention between the groups.

Results

The most frequent symptoms were fatigue (76.6%), insomnia (47.7%), pain (42.1%), and loss of appetite (37.4%). The symptom intensity analysis suggests that insomnia was the strongest symptom, followed by fatigue, loss of appetite, and pain. The IG experienced a significant improvement in terms of loss of appetite (P = 0.002) and a tendency toward less insomnia (P = 0.053).

Conclusions

The intervention significantly reduced appetite loss in cancer patients. Despite no effects observed in global QoL or functionality, the intervention yielded a tendency to improve insomnia, and this outcome should be investigated in future studies.

Is early integration of palliative home care in oncology treatment feasible and acceptable for advanced cancer patients and their health care providers? A phase 2 mixed-methods study

BACKGROUND

To support the early integration of palliative home care (PHC) in cancer treatment, we developed the EPHECT intervention and pilot tested it with 30 advanced cancer patients in Belgium using a pre post design with no control group. We aim to determine the feasibility, acceptability and perceived effectiveness of the EPHECT intervention.

METHODS

Interviews with patients (n = 16 of which 11 dyadic with family caregivers), oncologists and GPs (n = 11) and a focus group with the PHC team. We further analyzed the study materials and logbooks of the PHC team (n = 8). Preliminary effectiveness was assessed with questionnaires EORTC QLQ C-30, HADS and FAMCARE and were filled in at baseline and 12, 18 and 24 weeks.

RESULTS

In the interviews after the intervention period, patients reported feelings of safety and control and an optimized quality of life. The PHC team could focus on more than symptom management because they were introduced earlier in the trajectory of the patient. Telephone-based contact appeared to be insufficient to support interprofessional collaboration. Furthermore, some family caregivers reported that the nurse of the PHC team was focused little on them.

CONCLUSION

Nurses of PHC teams are able to deliver early palliative care to advanced cancer patients. However, more attention needs to be given to family caregivers as caregiver and client. Furthermore, the home visits by the PHC team have to be further evaluated and adapted. Lastly, professionals have to find a more efficient way to discuss future care.

Can case management improve cancer patients quality of life?: A systematic review following PRISMA

BACKGROUND

Cancer patients are associated with a series of long lasting and stressful treatments and experiencing, and case management (CM) has been widely used and developed with the aim to increase the quality of treatments and improve the patient care services. The purpose of this review is to identify and synthesize the evidence of randomized controlled trial studies to prove that case management could be one way to address the quality of life of cancer patients.

METHODS

We performed a literature search in 4 electronic bibliographic databases and snowball searches were performed to ensure a complete collection. Two review authors independently extracted and analyzed data. A data extraction form was used to collect the characteristics of case management intervention, report outcomes, and quality assessment.

RESULTS

Our searches identified 3080 articles, of which 7 randomized controlled trials met the inclusion criteria. The intervention was varied from the target population, measurement tools, duration of intervention, and so on, and 5 studies consistently showed improvement in the intervention group compared with control groups, no significant difference was found between health care costs of case management care services and the routine care services.

CONCLUSION

There is some evidence that case management can be effective in cancer patients quality of life. However, due to the heterogeneity in the target population, measurement tools, and results applied, no conclusion can be made from a meta-analysis on the present bias. More rigorously multi-centered randomized controlled studies should be provided with detailed information about intervention in future research.

The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers

BACKGROUND

Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families.

SEARCH METHODS

We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available.

MAIN RESULTS

We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I² = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I² = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I² = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I² = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I² = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision.

AUTHORS' CONCLUSIONS

Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.

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

Lung cancer is the most common cancer and leading cause of cancer mortality globally. Lung cancer is associated with significant morbidity, with symptoms often being poorly managed, causing significant symptom burden for both patients and their family caregivers. In people with life-limiting illnesses including advanced cancer, palliative care has been effective in improving symptom control, physical and mental wellbeing, quality of life, and survivorship; with benefits extending to caregivers while in the role and subsequently. Earlier integration of palliative care within oncology may be associated with improved patient outcomes, and has been supported by two Lancet commissions and national guidelines. The evidence for its effectiveness, however, has been mixed across the cancer spectrum. The aim of this review was to evaluate the current evidence for the effectiveness of early integrated palliative care in improving outcomes for people with lung cancer and their caregivers. Meta-analyses were performed where studies used the same measure. Otherwise, synthesis used a narrative approach. Similar to other types of advanced cancer, this review reveals mixed evidence for the effectiveness of early referral to palliative care and for the effectiveness of individual palliative interventions for people with lung cancer and their caregivers. Evidence that on-demand palliative care is equally, if not more effective than palliative care that is routinely provided, raises the question whether initiation and provision of palliative care as part of multidisciplinary lung cancer care ought to be guided by an early referral or need-based referral. Better understanding of what constitutes palliative care when delivered to people with lung cancer and their caregivers will help delineate the correlation with reported outcomes for these populations.

Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

In advanced cancer, patients want to know how their care options may affect survival and quality of life, but the impact of outpatient specialty palliative care on these outcomes in cancer is uncertain.

PURPOSE

To estimate the impact of outpatient specialty palliative care programs on survival and quality of life in adults with advanced cancer.

METHODS

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized controlled trials comparing outpatient specialty palliative care with usual care in adults with advanced cancer. Primary outcomes were 1 year survival and quality of life. Analyses were stratified to compare preliminary studies against higher-quality studies. Secondary outcomes were survival at other endpoints and physical and psychological quality-of-life measures.

RESULTS

From 2,307 records, we identified nine studies for review, including five high-quality studies. In the three high-quality studies with long-term survival data (n = 646), patients randomized to outpatient specialty palliative care had a 14% absolute increase in 1 year survival relative to controls (56% vs. 42%, p < .001). The survival advantage was also observed at 6, 9, 15, and 18 months, and median survival was 4.56 months longer (14.55 vs. 9.99 months). In the five high-quality studies with quality-of-life data (n = 1,398), outpatient specialty palliative care improved quality-of-life relative to controls (g = .18, p < .001), including for physical and psychological measures.

CONCLUSIONS

Patients with advanced cancer randomized to receive outpatient specialty palliative care lived longer and had better quality of life. Findings have implications for improving care in advanced cancer.

Summarizing the Evidence Base for Palliative Oncology Care: A Critical Evaluation of the Meta-analyses

Background:

Palliative care is a specialized approach to symptom management that focuses on supporting patients’ physical and psychological quality of life throughout the disease course. In oncology, palliative care has been increasing in utilization. The evidence base for such care is also growing through the use of randomized controlled trials (RCTs). In this review, we aim to integrate the findings from 4 meta-analyses of palliative oncology care RCTs to examine the impact of palliative care on physical and psychological quality of life and survival.

Method:

We considered 4 meta-analyses of palliative oncology care RCTs, which each used slightly different methodologies and analyses. Two of the meta-analyses included both outpatient and inpatient populations, whereas the remaining meta-analyses focused specifically on outpatient palliative oncology care.

Results:

All 4 meta-analyses reported a robust quality of life advantage for patients randomized to receive palliative care. Two meta-analyses identified a survival advantage, whereas the other 2 detected no survival differences. In 1 meta-analysis that examined high-quality RCTs of outpatient palliative oncology care, it was found that an increased survival probability for palliative care, compared with standard of care, was confined to 6- to 18-month follow-up.

Conclusions:

There is a growing evidence base for palliative oncology care, as highlighted by the 4 meta-analyses considered. Such care successfully improves both physical and psychological quality of life for patients with serious illnesses, especially cancer. Clinicians should educate patients and their caregivers about the findings of these meta-analyses. Finally, governmental policies should focus on increasing palliative care access.

Preferences to Receive Information about Palliative Care for Adult Patients

This research study aimed to describe preferences about factors related to receiving information regarding medical treatments and palliative care (PC) options for adult patients with a poor prognosis and/or their primary decision maker. A single-group descriptive study design and content analysis were utilized. Seven trained registered nurse (RN) study team members conducted interviews to obtain narrative data. All study participants preferred to learn PC services earlier in the illness trajectory and desired to learn about this service from nurses. Most reported a desire to have spouses and family involved in decisions about PC. Nearly all wanted to understand PC options ahead of time should treatment not go as planned.

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

Comparing Specialty and Primary Palliative Care Interventions: Analysis of a Systematic Review

Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC). Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions. Design: Systematic review secondary analysis. Setting/Subjects: RCTs of palliative care interventions. Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival. Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials. Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.

Exploratory analyses of the Danish Palliative Care Trial (DanPaCT): a randomized trial of early specialized palliative care plus standard care versus standard care in advanced cancer patients

BACKGROUND

Early and integrated specialized palliative care is often recommended but has still only been investigated in relatively few randomized clinical trials.

OBJECTIVE

To investigate the effect of early specialized palliative care plus standard care versus standard care on the explorative outcomes in the Danish Palliative Care Trial (DanPaCT).

METHODS

We conducted a randomized multicentre, parallel-group clinical trial. Consecutive patients with metastatic cancer were included if they had symptoms or problems that exceeded a predefined threshold according to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Outcomes were estimated as the differences between the intervention and the control groups in the change from baseline to the weighted mean of the 3- and 8-week follow-ups measured as areas under the curve.

RESULTS

In total, 145 patients were randomized to early specialized palliative care plus standard care versus 152 to standard care only. Early specialized palliative care had no significant effect on any of the symptoms or problems. Of the 21 items addressing satisfaction, specialized palliative care improved the item 'overall satisfaction with the help received from the health care system' with 9 points (95% confidence interval 3.8 to 14.2, p = 0.0006) and three other items (all p < 0.05).

CONCLUSION

In line with the analyses of the primary and secondary outcomes in DanPaCT, we did not find that specialized palliative care, as provided in DanPaCT, affected symptoms and problems. However, patients in the intervention group seemed more satisfied with the health care received than those in the standard care group.

TRIAL REGISTRATION

NCT01348048.

Phase 0–1 early palliative home care cancer treatment intervention study

Objectives

Recent studies have shown that the early provision of palliative care (PC) integrated into oncology in the hospital has beneficial effects on the quality of life of people who are dying and their family caregivers. However, a model to integrate palliative home care (PHC) early in oncology care is lacking. Therefore, our aim is to develop the Early Palliative Home care Embedded in Cancer Treatment (EPHECT) intervention.

Methods

We conducted a phase 0–1 study according to the Medical Research Council framework. Phase 0 consisted of a literature search on existing models for early integrated PC, and focus groups with PHC teams to investigate experiences with being introduced earlier. In phase 1, we developed a complex intervention to support the early integration of PHC in oncology care, based on the results of phase 0. The intervention components were reviewed and refined by professional caregivers and stakeholders.

Results

Phase 0 resulted in components underpinning existing interventions. Based on this information, we developed an intervention in phase 1 consisting of: (1) information sessions for involved professionals, (2) general practitioner as coordinator of care, (3) regular and tailored home consultations by the PHC team, (4) a semistructured conversation guide to facilitate consultations, and (5) interprofessional and transmural collaboration.

Conclusion

Taking into account the experiences of the PHC teams with being involved earlier and the components underpinning successful interventions, the EPHECT intervention for the home setting was developed. The feasibility and acceptability of the intervention will be tested in a phase II study.