Karl A. Lorenz, MD, MSHS; Joanne Lynn, MD, MA, MS; Sydney M. Dy, MD; Lisa R. Shugarman, PhD; Anne Wilkinson, MS, PhD; Richard A. Mularski, MD, MSHS, MCR; Sally C. Morton, PhD; Ronda G. Hughes, RN, MHS, PhD; Lara K. Hilton, BA; Margaret Maglione, PhD; Shannon L. Rhodes, MS; Cony Rolon, BA; Virginia C. Sun, BS, MSN; Paul G. Shekelle, MD, PhD
Disclaimer: The views expressed herein do not represent the views of the U.S. Department of Veterans Affairs, Agency for Healthcare Research and Quality (AHRQ), or National Institute of Nursing Research.
Grant Support: The National Institute of Nursing Research and the Agency for Healthcare Research and Quality (grant no. 290-02-0003) provided funding for this project. Dr. Lorenz was supported by a Veterans Affairs Health Services Research & Development Service Career Development Award, and Dr. Dy was supported by a K07 award from the National Cancer Institute (K07-CA096 783).
Potential Financial Conflicts of Interest:Grants received: K.A. Lorenz (Amgen).
Requests for Single Reprints: Karl A. Lorenz, MD, MSHS, Division of General Internal Medicine, Veterans Integrated Palliative Program, Veterans Affairs Greater Los Angeles Healthcare System, 11031 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Lorenz and Shekelle: Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073.
Dr. Lynn: Center for Medicare & Medicaid Services, Office of Standards and Quality, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850.
Dr. Dy: Johns Hopkins Bloomberg School of Public Health, Room 609, 624 North Broadway, Baltimore, MD 21205.
Drs. Shugarman and Maglione, Ms. Hilton, Ms. Rhodes, Ms. Rolon, and Ms. Sun: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208.
Dr. Wilkinson: Western Australia Center for Cancer and Palliative Care, Edith Cowan University, Building 19, Churchlands Campus, Pearson Street, Churchlands, WA 6018, Australia.
Dr. Mularski: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate, WIN 1060, Portland, OR 97227.
Dr. Morton: Research Triangle Institute, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.
Dr. Hughes: Agency for Healthcare Research and Quality, John M. Eisenberg Building, 540 Gaither Road, Rockville, MD 20850.
Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care.
To assess evidence about interventions to improve palliative and end-of-life care.
English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance.
Systematic reviews that addressed “end of life,” including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving.
Single reviewers screened 24 423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification.
Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure.
Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis.
Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.
Trajectories of late-life illness.
What are the critical elements for clinicians to address when caring for persons coming to the end of life?
What do definitions of the end of life suggest about identifying patients who could benefit from palliative approaches?
What treatment strategies work well for pain, dyspnea, and depression?
What elements are important in advance care planning for patients coming to the end of life?
What elements of collaboration and consultation are effective in promoting improved end of life care?
What elements of assessment and support are effective for serving caregivers, including family, when patients are coming to the end of life?
Study flow diagram.
*From the American Academy of Hospice and Palliative Medicine Fast Article Critical Summaries for Clinicians in Palliative Care and Annual Updates, November 2006 to January 2007. †Some reviews and interventions were relevant to more than 1 domain.
Table. Summary of Systematic Reviews and Additional Intervention Studies of Palliative and End-of-Life Care
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Anthony T Kerigan
March 3, 2008
Evidence for improving palliative care at the end of life
The recent review in the Annals of evidence of palliative care brings to light some of the challenges of summarising evidence in this area(1). The evidence that the authors have assembled supporting recommendations for the treatment of dyspnea in COPD illustrate these challenges.
Firstly,in defining end of life,there is much variability leading to incorporation of evidence from various stages of the natural history. Only one review in this area,examining opiods,focused on end of life(2). The others cited are drawn from studies of stable,but not end of life,COPD,which may,but not neccessarily, be applicable to patients with end stage COPD.
Secondly,the danger of "lumping" leads to a variety of conditions,COPD,heart failure,and advanced cancer,being included in the review of treatment of dyspnea(2) It is unlikely that the same mechanisms are responsible for dyspnea in all groups or that a particular treatment would have similar effects. In fact ,if the four studies of COPD are examined separately,they are not supportive of the positive recommendation of this review.
There will always be difficulties in studying the efficacy of interventions in the terminal phase of chronic conditions such COPD and heart failure. Extrapolation from studies in the more stable but less severe stages will need to made but with due allowance for the individual needs of the patient.
1.Lorenz KA,Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA et al. Evidence for improving palliative care at the end of life :A systematic review. Ann Intern Med. 2008;148:147-159
2.Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A systematic review of the use of opiods in the management of dyspnea. Thorax. 2002;57:939-944
Lorenz KA, Lynn J, Dy SM, et al. Evidence for Improving Palliative Care at the End of Life: A Systematic Review. Ann Intern Med. 2008;148:147–159. doi: 10.7326/0003-4819-148-2-200801150-00010
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Published: Ann Intern Med. 2008;148(2):147-159.
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