Associated with reduced healthcare and symptom burden, but not improvement in QOL

Palliative care is generally associated with cancer patients. But what is the effect of palliative care on end-of-live outcomes in patients with non-cancer illnesses?

According to a systematic review and analysis published in JAMA by Kieran L. Quinn, MD, MSc, Sinai Health System, Toronto, Ontario, and colleagues, palliative care in these patients is associated with a “modestly” lower symptom burden, as well as lower acute health care use, but no improvement in quality of life (QOL).

The study authors pointed out that while most of the current evidence concerning the benefits of palliative care is focused on cancer patients, “there are twice as many patients with non-cancer illness and palliative care needs than there are with cancer.” Trying to apply the evidence for palliative care to these illnesses could be problematic, since these illnesses have very different trajectories.

Therefore, in this study, Quinn and colleagues conducted a systematic review of palliative care randomized control trials in order to assess the association between palliative care and acute health care use, quality of life, and symptom burden in adults with non-cancer illness.

The systematic review and meta-analysis included 28 randomized control trials involving 13,664 patients (mean age 74 years, 46% female).

The type of trials included heart failure (10 trials, 4,068 patients), mixed disease (11 trials 8,119 patients), dementia (4 trials, 1,036 patients), and chronic obstructive pulmonary disease (3 trials, 441 patients).

Most of the studies (64%) were conducted in the United States, and 19 of the trials (68%) involved a specialist palliative care physician. Emergency department use was assessed in 10 trials, hospitalization was assessed in 15 trials, quality of life in 8 trials, symptoms in 14 trials, and advanced care planning in 9 trials.

The authors found that palliative care, compared with usual care, was statistically significantly associated with less emergency department use (20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]), less hospitalization (38% versus 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]), and lower symptom burden (pooled standardized mean difference, −0.12; [95% CI, −0.20 to −0.03]).

Palliative care was not significantly associated with disease-generic QOL (standard mean difference, 0.18 [95% CI, −0.24-0.61]) or disease-specific QOL (standard mean difference, 0.07 [95% CI, −0.09 to 0.23]) but was associated with advance care planning. However, Quinn and colleagues noted that “significant heterogeneity between trials in both analyses weakened confidence in these findings.”

The authors also pointed out that there are several limitations to their findings. For example, analysis of some of the outcomes was based predominantly on heart failure trials, limiting their applicability to other chronic illnesses. Their analysis also excluded a number of other important conditions, such as neurodegenerative disorders, chronic lung diseases other than COPD, rheumatologic diseases, and HIV/AIDS, and included trials of mixed disease involving a minority of patients with cancer, which could have influenced their findings.

“The collective findings from this study will help to define the specific associated benefits of palliative care in patients with non-cancer illness, which will inform the ongoing design and delivery of palliative care for patients, clinicians, and policy makers in health care systems,” Quinn and colleagues concluded.

In an editorial accompanying the study, Krista L. Harrison, PhD, Division of Geriatrics, University of California, San Francisco, and colleagues asked why palliative care — an intervention devoted to QOL — appears not to be associated with a better quality of life.

Harrison and her colleagues pointed out that several of the palliative care interventions included in the analysis did not self-identify as palliative care and would not have been considered complete palliative care interventions by palliative care experts. Furthermore, they noted that those analyses that were limited to interventions which involved palliative care physicians or interdisciplinary teams showed clinically meaningful improvements in QOL.

“Findings might be interpreted as indicators of the ’dose response’ of training, expertise, and provision of palliative care,” wrote Harrison and her colleagues. “Further research and consensus are needed to define the minimum dose that makes an intervention palliative care.”

They concluded that while the findings of the systemic review and meta-analysis shows that palliative care is associated with reduced acute care service use, reduced symptom burden, and increased advance care planning among non-cancer patients, it also “underscores the need to fund, develop, and test interventions that provide relief of symptoms, interventions that improve quality of life, and interventions for diseases for which little or no randomized trial–level evidence currently exists.”

  1. Pallative care for noncancer patients is associated with a lower symptom burden and reduced use of healthcare services.

  2. Note that palliative care was not associated with improved quality of life.

Michael Bassett, Contributing Writer, BreakingMED™

None of the authors quoted in this article disclosed any relevant relationships.

Cat ID: 494

Topic ID: 398,494,282,494,791,570,255,925