Evidence for improving palliative care at the end of life

A systematic review

Karl A. Lorenz, Joanne Lynn, Sydney E Dy, Lisa R. Shugarman, Anne Wilkinson, Richard A. Mularski, Sally C. Morton, Ronda G. Hughes, Lara K. Hilton, Margaret Maglione, Shannon L. Rhodes, Cony Rolon, Virginia C. Sun, Paul G. Shekelle

Research output: Contribution to journalArticle

Abstract

Background: 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. Purpose: To assess evidence about interventions to improve palliative and end-of-life care. Data Sources: 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. Study Selection: 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. Data Extraction: 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. Data Synthesis: 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 multicomponent 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. Limitations: 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. Conclusion: 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.

Original languageEnglish (US)
Pages (from-to)147-159
Number of pages13
JournalAnnals of Internal Medicine
Volume148
Issue number2
StatePublished - Jan 15 2008

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Palliative Care
Dyspnea
Advance Care Planning
Chronic Disease
Terminal Care
Heart Failure
Opioid Analgesics
Caregivers
Dementia
Neoplasms
Depression
Pain
Quality of Health Care
Information Storage and Retrieval
Serotonin Uptake Inhibitors
Bibliography
MEDLINE
Radioisotopes
Psychotherapy
Antidepressive Agents

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Lorenz, K. A., Lynn, J., Dy, S. E., Shugarman, L. R., Wilkinson, A., Mularski, R. A., ... Shekelle, P. G. (2008). Evidence for improving palliative care at the end of life: A systematic review. Annals of Internal Medicine, 148(2), 147-159.

Evidence for improving palliative care at the end of life : A systematic review. / Lorenz, Karl A.; Lynn, Joanne; Dy, Sydney E; Shugarman, Lisa R.; Wilkinson, Anne; Mularski, Richard A.; Morton, Sally C.; Hughes, Ronda G.; Hilton, Lara K.; Maglione, Margaret; Rhodes, Shannon L.; Rolon, Cony; Sun, Virginia C.; Shekelle, Paul G.

In: Annals of Internal Medicine, Vol. 148, No. 2, 15.01.2008, p. 147-159.

Research output: Contribution to journalArticle

Lorenz, KA, Lynn, J, Dy, SE, Shugarman, LR, Wilkinson, A, Mularski, RA, Morton, SC, Hughes, RG, Hilton, LK, Maglione, M, Rhodes, SL, Rolon, C, Sun, VC & Shekelle, PG 2008, 'Evidence for improving palliative care at the end of life: A systematic review', Annals of Internal Medicine, vol. 148, no. 2, pp. 147-159.
Lorenz KA, Lynn J, Dy SE, Shugarman LR, Wilkinson A, Mularski RA et al. Evidence for improving palliative care at the end of life: A systematic review. Annals of Internal Medicine. 2008 Jan 15;148(2):147-159.
Lorenz, Karl A. ; Lynn, Joanne ; Dy, Sydney E ; Shugarman, Lisa R. ; Wilkinson, Anne ; Mularski, Richard A. ; Morton, Sally C. ; Hughes, Ronda G. ; Hilton, Lara K. ; Maglione, Margaret ; Rhodes, Shannon L. ; Rolon, Cony ; Sun, Virginia C. ; Shekelle, Paul G. / Evidence for improving palliative care at the end of life : A systematic review. In: Annals of Internal Medicine. 2008 ; Vol. 148, No. 2. pp. 147-159.
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