To what degree is palliative care integrated in guidelines and pathways for adult cancer patients in Europe: a systematic literature review

Benefits of integrating palliative care: a qualitative exploration of the perspectives of palliative care providers in a tertiary health facility in Ghana

Background

Integration of palliative care (PC) services entails combining administrative, organisational, clinical and service elements to ensure continuity of care between all parties participating in the care network of patients. There is a need to understand the benefits of integrating PC to inform policy making and advance advocacy, especially in resource-constrained settings such as Ghana where PC is sub-optimally implemented. Yet, existing research in Ghana is sparse on what benefits are likely to be experienced as a result of integrating PC.

Objective

The study explored service providers' perspectives on the benefits of integrating PC in Ghana.

Design

The design was an exploratory descriptive qualitative research design.

Methods

A total of seven in-depth interviews were conducted using semi-structured interview guides. The data were managed using NVivo-12. Inductive thematic analysis was carried out following Haase's modification of Colaizzi's approach to qualitative research analysis. The study follows the COREQ guidelines and the ICMJE recommendations.

Result

Two main themes emerged: patient-related outcomes, and system/institution-related outcomes. For the patient-related outcomes, the following sub-themes emerged: restored hope, appreciated care and better preparation for the end of life (EoL). The emerging sub-themes under the system/institution-related outcomes include the following: early initiation of care, enhanced communication between primary healthcare providers and the PC team and strengthening staff capacity to provide PC services.

Conclusion

In conclusion, there are substantial benefits to be experienced from integrating PC. For the patients, it would restore shattered hopes, result in appreciated care and better preparation for the EoL. For the healthcare system, it would promote early initiation of care, enhance communication between primary healthcare providers and the PC team and strengthen service providers' capacity to provide PC services. This study, thus, furthers the case for a more integrated PC service in Ghana.

Identifying Core Domains to Assess the "Quality of Death": A Scoping Review

CONTEXT

There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines.

OBJECTIVES

Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems.

METHODS

PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles.

RESULTS

A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication.

CONCLUSION

The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.

Gathering policymakers' perspectives as an essential step in planning and implementing palliative care services at a national level: an example from a resource-limited country

BACKGROUND

Despite increasing recognition of the role played by palliative care (PC) services, the priorities of policymakers in supporting PC remain unclear and have sometimes engendered controversy. There are few studies exploring policymakers' perspectives towards PC services, with most shedding light on obstacles to PC development. Furthermore, no study has explored policymakers' perspectives towards providing PC at the national level in resource-limited countries. This study provides a platform for providing PC as part of the Palestinian healthcare system (HCS) by exploring policymakers' perspectives on PC, an essential step to developing a PC programme.

METHODS

A descriptive qualitative study design was employed using semi-structured interviews. Participants were those identified as responsible for making executive and legislative decisions about health services (including PC) in the HCS. Data were analysed using qualitative content analysis.

RESULTS

Twelve decision and policymakers participated in the study. Four categories were generated from the content analysis: (1) the nature of current PC healthcare services, (2) the potential benefits of PC, (3) challenges to providing PC, and (4) considerations in providing PC. The current PC services provided to Palestinian patients with life-limiting illnesses and their families are not comprehensive, and are limited to symptom management. There is a Palestinian national strategic plan for developing PC; however, the development goals are not clearly defined, and the plan's capabilities are inadequate. Several challenges to the provision of PC were found to relate to issues of education and training, the allocation of funding, and the availability of medications.

CONCLUSIONS

Integrating PC into the Palestinian university curricula as a compulsory course and establishing higher degree programmes in PC to overcome the shortage of PC specialists is required. Developing policies aligned with national laws could help enhance health services to patients and their families and resolve several challenges. Cooperating with national and international institutions in seeking funding could boost PC development and medication availability.

Opportunities for Integrating Palliative Care in Ghana

INTRODUCTION

The integration of palliative care (PC) services is characterized by several barriers and challenges, which may include misperception of PC services as end-of-life care, poor referral systems, inadequate financial support, regulatory barriers, and the small size of PC professional workforce. Beyond these barriers, the question remains: what opportunities exist to facilitate the integration of PC in managing patients' conditions? Notably, for a resource-constrained country like Ghana, unearthing existing facilitating factors would enable the country to leverage the opportunities these factors present to promote PC integration.

OBJECTIVE

The aim of this study is to explore opportunities that exist to facilitate PC integration from the perspective of PC service providers.

METHODS

An exploratory descriptive qualitative research design was used. Using semi-structured interview guides, seven face-to-face interviews were conducted with PC service providers in a tertiary hospital in Ghana. Data were managed using QSR NVivo-12. Inductive thematic analysis was carried out following Haase's modification of Colaizzi's approach to qualitative research analysis.

RESULTS

From the inductive thematic analysis, it was revealed that four main opportunities exist to facilitate PC integration. These included the availability of a PC team and teamwork, knowledge level of service providers, enabling attitudes of service providers, and the incorporation of PC in the medical school curriculum.

CONCLUSION

The study concludes that to facilitate the integration of PC in a tertiary health facility, there is a need to leverage on the supportive attitudes of service providers. Also, there is a need to expand the incorporation of PC education in the curriculum of all health and allied health courses. This could help create a pool of primary healthcare providers who can provide generalist PC services promptly. The study also underscores a need for continuous professional development.

Winners and Losers in Palliative Care Service Delivery: Time for a Public Health Approach to Palliative and End of Life Care

Background: Consumer experience of palliative care has been inconsistently and selectively investigated. Methods: People in Western Australia who had experienced a life limiting illness in the past five years were recruited via social media and care organisations (2020) and invited to complete a cross sectional consumer survey on their experiences of the care they received. Results: 353 bereaved carers, current carers and patients responded. The winners, those who received the best quality end-of-life care, were those who were aware of palliative care as an end-of-life care (EOLC) option, qualified for admission to and were able to access a specialist palliative care program, and with mainly a cancer diagnosis. The losers, those who received end-of-life care that was adequate rather than best practice, were those who were unaware of palliative care as an EOLC option or did not qualify for or were unable to access specialist palliative care and had mainly a non-cancer diagnosis. Both groups were well supported throughout their illness by family and a wider social network. However, their family carers were not adequately supported by health services during caregiving and bereavement. Conclusions: A public health approach to palliative and end of life care is proposed to integrate tertiary, primary, and community services through active consumer engagement in the design and delivery of care. Therefore, suggested strategies may also have relevance in many other international settings.

Palliative and End-of-Life Care Service Models: To What Extent Are Consumer Perspectives Considered?

This article presents evidence found in a search of national and international literature for patient preferences concerning settings in which to receive palliative care and the appropriateness of different models of palliative care. The purpose was to inform end-of-life care policy and service development of the Western Australian Department of Health through a rapid review of the literature. It was found that consumer experience of palliative care is investigated poorly, and consumer contribution to service and policy design is limited and selective. Most patients experience a mix of settings during their illness, and evidence found by the review has more to do with qualities and values that will contribute to good end-of-life care in any location. Models of care do not make systematic use of the consumer data that are available to them, although an increasingly common theme is the need for integration of the various sources of care supporting dying people. It is equally clear that most integration models limit their attention to end-of-life care provided by health services. Transitions between settings merit further attention. We argue that models of care should take account of consumer experience not by incorporating generalised evidence but by co-creating services with local communities using a public health approach.

Palliative care utilization in calciphylaxis: a single-center retrospective review of 121 patients (1999-2016)

BACKGROUND

Calciphylaxis is a debilitating dermatological condition associated with high rates of morbidity and mortality. Palliative care offers a multidisciplinary approach to addressing symptoms and goals of care in patients with serious medical diagnoses. Involvement of palliative services for calciphylaxis is infrequently reported in the literature. The purpose of this report is to assess rates of palliative and pain consultation for patients with calciphylaxis.

METHODS

This is a comprehensive, single-institution retrospective chart review of 121 eligible patients with a diagnosis of calciphylaxis treated at Mayo Clinic in Rochester, Minnesota, from 1999 to 2016. Inclusion criteria were an indisputable diagnosis of calciphylaxis based on clinical, histopathologic, and radiographic features. One hundred twenty-one patients met inclusion criteria.

RESULTS

Fifty-one patients (42%) received either a palliative (n = 15) or pain (n = 20) consultation, or both (n = 16). Patients with a palliative care consultation were younger compared with those without (mean ages 57 vs. 62 years, P = 0.046). In 104 patients (86%), psychiatric symptoms were not assessed.

CONCLUSIONS

In this cohort of patients with calciphylaxis, the majority do not receive palliative and pain care consultations. Psychiatric complications are inconsistently addressed. These observations highlight practice gaps in the care of patients with calciphylaxis.

Global Perspectives on Palliative Care for Cancer Patients: Not All Countries Are the Same

PURPOSE OF THE REVIEW

The integration of cancer-related palliative care is essential to holistic, quality cancer care. While some similarities exist between countries, this manuscript will focus on five differences that impact palliative care for cancer patients including the epidemiology of cancer and related symptoms, cancer-specific integration into care, palliative care education, economic development of the country, and cultural and religious differences.

RECENT FINDINGS

The epidemiology of cancer varies around the world resulting in variable symptoms and the need for individualized approaches to palliative care. While palliative care is integrated in some countries, it is lacking in over half of the world, and specific integration into cancer care is virtually absent. Education and training are the key to expansion, and yet oncology-focused palliative care education is lacking or is not well-reported in the literature. To complicate this global lens even further are the economic disparities that exist. Low-to-middle-income countries (LMICs) are resource poor and have the fewest resources and least amount of integration, and yet patients with advanced cancer are over-represented in these countries. Essential to cancer-related palliative care is a tailored approach that addresses cultural and religious differences around the globe. Palliative care is developing around the globe and yet palliative care specific for cancer patients is in its infancy. Cancer care professionals should (1) understand the epidemiologic differences that exist globally and the impact this has on palliative care, (2) integrate palliative care into the cancer care arena, (3) provide cancer-specific palliative education focused on the cancer trajectory from diagnosis through survivorship and end of life, (4) advocate for LMICs, which suffer from a lack of resources and services, and (5) understand cultural and religious differences that exist to provide holistic and sensitive cancer-related palliative care.

Characteristics and Prognosis of Patients Who Receive Noninvasive Ventilation and Present Limitation of Life Support Treatment: The LLST-NIVCat Multicenter Cohort Study

BACKGROUND

Patients who receive noninvasive ventilation (NIV) in the emergency department (ED) sometimes have a limitation of life support treatment (LLST). The characteristics and prognosis in these patients may be worse, however, few studies have been carried out in this respect.

OBJECTIVE

Analyze the differences between patients receiving NIV in the ED with LLST (NIV-LLST) or without LLST (NIV-noLLST) and their impact on in-hospital mortality, as well as investigate in-hospital mortality in the NIV-LLST group.

METHOD

We performed a secondary analysis of data from the NIVCat registry. This was a prospective, multicenter, analytical cohort study with consecutive inclusion of patients receiving NIV from February to March 2015 in 11 hospital EDs in Spain. Data on the baseline characteristics, the acute episode, and final patient destination were collected. The dependent variable was all-cause in-hospital mortality.

RESULTS

We analyzed 152 cases receiving NIV, 66 (43.4%) of whom had NIV-LLTS. Age ≥ 75 years was associated with NIV-LLST. In-hospital mortality was higher in the NIV-LLST group, with an adjusted hazard ratio of 2.50 (95% confidence interval [CI] 1.03-6.06). Patients with NIV-LLST presenting an exacerbation of chronic obstructive pulmonary disease (COPD) presented the lowest mortality, with an odds ratio of 0.27 (95% confidence interval 0.08-0.93), compared with the remaining patients.

CONCLUSION

In our cohort of patients receiving NIV in the ED, the presence of LLST is frequent and is associated with high hospital mortality. The NIV-LLST patients with a COPD exacerbation have a better prognosis than NIV-LLST patients with other diseases.

Disseminating research findings using a massive online open course for maximising impact and developing recommendations for practice

Background

Developing recommendations for how we deliver healthcare is often left to leading experts in a field. Findings from the Integrated Palliative Care in cancer and chronic conditions (InSup-C) study, which aimed to identify best practice in integrated palliative care in cancer, chronic obstructive pulmonary disease (COPD) and heart failure, led to recommendations developed through an expert consultation process. We also wanted to develop these recommendations further with participants who were largely clinicians and members of the public.

Methods

Results from the InSup-C study were disseminated through a three-week massive open online course (MOOC) which ran in 2016, 2017 and 2019. The first course helped develop the final recommendations, which were ranked by MOOC participants in the subsequent courses. MOOC participants were predominantly clinicians, but also academics and members of the public. They rated how important each recommendation was on a 9 point scale (9 most important). Descriptive statistics were used to analyse the ratings. The results were compared to findings from the consultation.

Results

Five hundred fifteen completed the last part of the course where the recommendations were ranked, of which 195 (38%) completed the ratings. The top recommendations related to: need to expand palliative care to non-malignant conditions; palliative care needs to include different dimensions of care including physical, psychological and spiritual; policies and regulations assessments should be made regularly; palliative care integration should be mandatory; and there should be greater availability of medicines. These differed compared to the top ranked recommendations by the consultation panel in relation to the importance of leadership and policy making. This may indicate that clinicians are more focused on daily care rather than the (inter) national agenda.

Conclusions

Whilst both sets of recommendations are important, our study shows that we need to include the views of clinicians and the public rather than rely upon leading expert opinion alone. To keep recommendations fresh we need both the input of clinicians, the public and experts. When disseminating findings, MOOCs offer a useful way to gain greater reach with clinicians and the public, and importantly could be a vehicle to validate recommendations made by leading expert panels.

Clinical research in cancer palliative care: a metaresearch analysis

OBJECTIVE

This metaresearch of the clinicaltrials.gov database aims to evaluate how clinical research on palliative care is conducted within the setting of advanced cancer.

METHODS

Clinicaltrials.gov was searched to identify registered studies recruiting patients with cancer, and investigating issues relevant to palliative care. The European Organisation for Research and Treatment of Cancer QLQ-C15-PAL (Quality of Life in palliative cancer care patients) questionnaire was taken into account to define the research domains of interest. Studies investigating cancer-directed therapy, management of cancer treatment-related adverse events and diagnostic tests were excluded. Publication status was crosschecked using PubMed.

RESULTS

Of 3950 identified studies, 514 were included. The most frequent reason for exclusion was cancer-directed therapy (2491). In 2007-2012, 161 studies were registered versus 245 in 2013-2018. Included studies were interventional (84%) or observational (16%). Most studies were monocentric (60%), sponsored by academia (79%), and conducted in North America (57%) or Europe (25%). Seventy-nine per cent of studies evaluated a heterogeneous population (>1 tumour type). Interventional studies most frequently investigated systemic drugs (34%), behavioural interventions (29%) and procedures for pain (24%). Pain, quality of life and physical function were the most frequently studied research domains (188, 95 and 52 studies, respectively). The most applied primary outcome measures were efficacy/symptom control (61%), quality of life (14%) and feasibility (12%). Only 16% of the closed studies had published results in PubMed.

CONCLUSIONS

Our study describes the heterogeneous landscape of studies conducted to address the issues of patients with advanced cancer in palliative care. Albeit the observed increase in the number of studies over the last decade, the generalisation of the results brought by the existing trials is limited due to methodological issues and lack of reporting. A greater effort is needed to improve clinical research that supports evidence-based palliative cancer care.

International review of national-level guidelines on end-of-life care with focus on the withholding and withdrawing of artificial nutrition and hydration

AIM

The purpose of the present study was to collate examples of end-of-life care guidelines from various counties, examine their contents, and gain an overall picture of how end-of-life care guidance is offered to physicians and care providers internationally.

METHODS

In this study, eight researchers worked independently to source and examine national-level end-of-life care guidelines from different countries and regions. Data collected by each researcher were gathered into a unified table. The items in the table included basic information (publisher, year, URL etc.) and more specific items, such as the presence/absence of legal information and family's role in decision-making. These data were then used to identify trends, and examine the mechanics and delivery of guidance on this topic.

RESULTS

A total of 54 guidelines were included in the study. All the guidelines were published between 2000 and 2016, and 60% (n = 33) were published after 2012. The length of the guidelines varied from two to 487 pages (median 38 pages), and had different target audiences - both lay and professional. A total of 38 (70%) of the guidelines included information about the relevant laws and legal issues, 47 (87%) offered advice on withholding and withdrawing treatment, 46 (85%) discussed the family's role in decision-making and 46 (85%) emphasized the teamwork aspect of care.

CONCLUSIONS

The present findings show that end-of-life care guidelines are generally made reactively in response to the trend toward patient-centered care, and that to create effective guidelines and implement them requires multilevel cooperation between governmental bodies, healthcare teams, and patients and their families. Geriatr Gerontol Int 2019; 19: 847-853.

Recommendations on priorities for integrated palliative care: transparent expert consultation with international leaders for the InSuP-C project

BACKGROUND

The World Health Organisation (WHO) endorses integrated palliative care which has a significant impact on quality of life and satisfaction with care. Effective integration between hospices, palliative care services, hospitals and primary care services are required to support patients with palliative care needs. Studies have indicated that little is known about which aspects are regarded as most important and should be priorities for international implementation. The Integrated Palliative Care in cancer and chronic conditions (InSup-C) project, aimed to investigate integrated practices in Europe and to formulate requirements for effective palliative care integration. It aimed to develop recommendations, and to agree priorities, for integrated palliative care linked to the InSuP-C project.

METHODS

Transparent expert consultation was adopted at the approach used. Data were collected in two phases: 1) international transparent expert consultation using face-to-face roundtable discussions at a one day workshop in Brussels, and 2) via subsequent online cross-sectional survey where items were rated to indicate degree of agreement on their importance and ranked to indicate priority for implementation. Workshop discussions used content analysis to develop a list of 23 recommendations, which formed the survey questionnaire. Survey analysis used descriptive statistics and qualitative content analysis of open responses.

RESULTS

Thirty-six international experts in palliative care and cancer care, including senior clinicians, researchers, leaders of relevant international organisations and funders, were invited to a face-to-face workshop. Data were collected from 33 (19 men, 14 women), 3 declined. They mostly came from European countries (31), USA (1) and Australia (1). Twenty one of them also completed the subsequent online survey (response rate 63%). We generated 23 written statements that were grouped into the organisational constructs: macro (10), meso (6) and micro (7) levels of integration of palliative care. Highest priority recommendations refer to education, leadership and policy-making, medium priority recommendations focused on funding and relationship-building, and lower priority recommendations related to improving systems and infrastructure.

CONCLUSIONS

Our findings suggest that amongst a group of international experts there was overall good agreement on the importance of recommendations for integrated palliative care. Understanding expert's priorities is important and can guide practice, policymaking and future research.

Professionals' perceptions and current practices of integrated palliative care in chronic heart failure and chronic obstructive pulmonary disease: a qualitative study in Belgium

Background

Patients with Chronic Heart Failure (CHF) and patients with Chronic Obstructive Pulmonary Disease (COPD) share similar symptom burden with cancer patients, however, they are unlikely to receive palliative care (PC) services. This article examines the perceptions of health care professionals and the current practices of integrated palliative care (IPC) in Belgium.

Methods

Cardiologists and pulmonologists, working in primary care hospitals in Belgium, participated in this study with semi-structured interviews based on IPC indicators. One researcher collected, transcribed verbatim the interviews and carried out their thematic analysis. To increase the reliability of the coding, a second researcher coded a random 30% of the interviews.

Results

A total of 22 CHF/COPD specialists participated in the study. The results show that IPC and its potential benefits are viewed positively. A number of IPC components like the holistic approach (physical, psychological, social, spiritual aspects) via multidisciplinary teams, prognosis discussion and illness limitations, patient goals assessment, continuous goal adjustment, reduction of suffering and advanced care planning are partially implemented in several health centers. However, PC specialists are absent from such implementations and PC is still an end-of-life care.

Conclusions

Misconceptions about PC and its association to death and end-of-life appear to be decisive factors for the exclusion of PC specialists and the late initiation of PC itself. The implementation of IPC components is not associated to PC, and as such, leads to suboptimal results. Improved education and enhanced communication is expected to alleviate existing challenges and thus improve the quality of life for the patients.

Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries

BACKGROUND:

Integrated palliative care aims at improving coordination of palliative care services around patients’ anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking.

AIM:

To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe.

DESIGN:

Qualitative group interview design.

SETTING/PARTICIPANTS:

A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses (n = 66; 46%) and physicians (n = 50; 35%).

RESULTS:

The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services.

CONCLUSION:

Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings.

Is the content of guidelines/pathways a barrier for the integration of palliative Care in Chronic Heart Failure (CHF) and chronic pulmonary obstructive disease (COPD)? A comparison with the case of cancer in Europe

BACKGROUND

There is a notable inequity in access to palliative care (PC) services between cancer and Chronic Heart Failure (CHF)/Chronic Obstructive Pulmonary Disease (COPD) patients which also translates into discrepancies in the level of integration of PC. By cross-examining the levels of PC integration in published guidelines/pathways for CHF/COPD and cancer in Europe, this study examines whether these discrepancies may be attributed to the content of the guidelines.

DESIGN

A quantitative evaluation was made between integrated PC in published guidelines for cancer and CHF/COPD in Europe. The content of integrated PC in guidelines/pathways was measured using an 11 point integrated PC criteria tool (IPC criteria). A statistical analysis was carried out to detect similarities and differences in the level of integrated PC between the two groups.

RESULTS

The levels of integration between CHF/COPD and cancer guidelines/pathways have been shown to be statistically similar. Moreover, the quality of evidence utilized and the date of development of the guidelines/pathways appear not to impact upon the PC integration in the guidelines.

CONCLUSION

In Europe, the empirically observed imbalance in integration of PC for patients with cancer and CHF/COPD may only partially be attributed to the content of the guidelines/pathways that are utilized for the PC implementation. Given the similarities detected between cancer and CHF/COPD, other barriers appear to play a more prominent role.

The role of informal caregivers at the end of life: providing support through Advance Care Planning

In the palliative phase of a person's illness, the needs of the patient and informal caregivers are paramount. Caregivers often look to palliative care practitioners for support, guidance and emotional comfort. This article reviews the role of the informal caregiver at the end of life, summarising their concerns and needs. The paper also highlights caregiver difficulties in making the coping transition when the patient's medical condition becomes advanced and they require end-of-life care. The focus of the review is placed on discussions about Advanced Care Planning (ACP). ACP is a complex legal, ethical and practical issue that can enable caregivers to consider future strategies and enable them to provide high quality care at the end of life. The paper looks at some of the ethical and legal issues associated with this sensitive end-of-life issue.

Integrated palliative care in the Spanish context: a systematic review of the literature

Background

Integrated palliative care (IPC) involves bringing together administrative, organisational, clinical and service aspects in order to achieve continuity of care between all actors involved in the care network of patients receiving palliative care (PC) services. The purpose of this study is to identify literature on IPC in the Spanish context, either in cancer or other advanced chronic diseases.

Methods

Systematic review of the literature about IPC published in Spain between 1995 and 2013. Sources searched included PubMed, Cochrane Library, Cinahl, the national palliative care Journal (Medicina Paliativa), and Google. Evidence on IPC in care models, pathways, guidelines and other relevant documents were searched. Additionally, data were included from expert sources. Elements of IPC were considered based on the definition of IPC and the Emmanuel´s IPC tool. The main inclusion criterion was a comprehensive description of PC integration.

Results

Out of a total of 2,416 titles screened, 49 were included. We found two models describing IPC interventions achieving continuity and appropriateness of care as a result, 12 guidelines or pathways (most of them with a general approach including cancer and non-cancer and showing a theoretical IPC inclusion as measured by Emmanuel’s tool) and 35 other significant documents as for their context relevance (17 health strategy documents, 14 analytical studies and 4 descriptive documents). These last documents comprised respectively: regional and national plans with an IPC inclusion evidence, studies focused on IPC into primary care and resource utilisation; and descriptions of fruitful collaboration programmes between PC teams and oncology departments.

Conclusions

The results show that explications of IPC in the Spanish literature exist, but that there is insufficient evidence of its impact in clinical practice. This review may be of interest for Spanish-speaking countries and for others seeking to know the status of IPC in the literature in their home nations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0120-9) contains supplementary material, which is available to authorized users.