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A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

Open ArchivePublished:October 30, 2018DOI:https://doi.org/10.1016/j.jpainsymman.2018.09.008

      Abstract

      Context

      Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers.

      Objectives

      The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

      Methods

      Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel.

      Results

      We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews).

      Conclusion

      A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.

      Key Words

      Introduction

      Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients with serious illness and their caregivers. Inpatient palliative care programs have increased their penetration by 85% from 2008 to 2015.
      • Dumanovsky T.
      • Rogers M.
      Trends in hospital palliative care from the National Palliative Care Registry™ (S723).
      In 2015, 67% of hospitals with 50 or more beds in the U.S. reported having an interdisciplinary palliative care team, up from 53% in 2008.
      • Morrison R.S.
      • Meier D.E.
      America’s Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals.
      Recent data showing a decrease in length of stay before a palliative care consult and an increase in hospital discharges after a palliative care consult indicate that patients are being referred to palliative care earlier and thus better able to maximize the benefit of these services.
      • Tamara Dumanovsky P.
      The National Palliative Care Registry™: Trends in Hospital Palliative Care Since 2008.
      A rapidly aging population with complex care needs, growing fiscal pressures, and increasing attention on value-based payment will likely accelerate emphasis on palliative care services in the U.S.
      Concurrently, research in palliative care has significantly expanded. Several important and well-designed studies have demonstrated that hospice and palliative services can improve patient and caregiver quality of life, satisfaction with care, and end-of-life care communication and care planning, as well as reduce costs and unwanted care among a range of conditions and settings.
      • Bakitas M.
      • Lyons K.D.
      • Hegel M.T.
      • et al.
      Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial.
      • Brumley R.
      • Enguidanos S.
      • Jamison P.
      • et al.
      Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care.
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      • Pantilat S.Z.
      • O'Riordan D.L.
      • Dibble S.L.
      • Landefeld C.S.
      Hospital-based palliative medicine consultation: a randomized controlled trial.
      • Rabow M.W.
      • Dibble S.L.
      • Pantilat S.Z.
      • McPhee S.J.
      The comprehensive care team: a controlled trial of outpatient palliative medicine consultation.
      • Aiken L.S.
      • Butner J.
      • Lockhart C.A.
      • et al.
      Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill.
      • Engelhardt J.B.
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      • et al.
      Effects of a program for coordinated care of advanced illness on patients, surrogates, and healthcare costs: a randomized trial.
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      • Ferguson L.A.
      • Davis A.D.
      • et al.
      Assessing end-of-life preferences for advanced dementia in rural patients using an educational video: a randomized controlled trial.
      • Au D.H.
      • Udris E.M.
      • Engelberg R.A.
      • et al.
      A randomized trial to improve communication about end-of-life care among patients with COPD.
      • Casarett D.
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      • Morales K.
      • et al.
      Improving the use of hospice services in nursing homes: a randomized controlled trial.
      • Curtis J.R.
      • Nielsen E.L.
      • Treece P.D.
      • et al.
      Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.
      There is a growing body of research on the use and effectiveness of symptom management approaches, palliative care delivery models, and psychosocial, spiritual, and grief support services that can help to guide clinical practice and improve quality. As our understanding of what works in palliative and end-of-life care is growing, there is a need to usefully synthesize evidence across key areas about which interventions work, for whom, and under what conditions, to more directly guide clinical practice, quality measurement, and training/education, and to help make evidence-based policy decisions.
      Clinical practice guidelines for palliative care provide a foundation for improving the quality and delivery of palliative care in the context of the rapid expansion of the field. The National Consensus Project (NCP) Clinical Practice Guidelines for Quality Palliative Care have played a critical role in advancing palliative care practice and providing guidance and support for providers. These guidelines informed the National Quality Forum palliative care framework endorsed in 2006 in addition to 38 preferred practices that provided a foundation for palliative care quality measurement and reporting.
      The NCP Guidelines are consensus-based guidelines, informed by expert knowledge and current research. In response to an increasing need to develop evidence-based guidelines to inform policymakers, payors, and practitioners, the fourth edition of the guidelines will include and be informed by a robust systematic review of current evidence in palliative care. Palliative care clinical practice guidelines grounded in research evidence will help to ensure adoption and adherence by health care providers, health plans, accrediting agencies, and regulatory agencies and will assure they remain as the gold standard for informing practice and policy within the field.
      We therefore undertook a systematic review of current evidence in palliative care to inform the fourth version of the NCP guidelines. In this study, we describe the review methods, key findings, and implications for the field.

      Methods

      Overview

      This systematic review synthesizes the best current evidence for palliative care interventions across eight domains that structure the NCP clinical practice guidelines. The systematic review was supported by a technical expert panel. The review is registered in PROSPERO (CRD42018100065) and followed PRISMA guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      Palliative care is defined as care, services, or programs with the primary intent of relieving suffering and improving health-related quality of life, including dimensions of physical, psychological/emotional, social, and spiritual well-being. Ten key questions (KQs) were selected to guide the review (Supplemental File: Key Questions Search and Eligibility Criteria Table).

      Search Strategy

      An experienced evidence-based practice center librarian designed and executed all searches. We searched the Cochrane Database of Systematic Reviews (health research), the database of systematic reviews by the Campbell Collaboration (health and social work research), PubMed (biomedical literature), PsycINFO (psychological literature), EMBASE (pharmacology research), CINAHL (nursing research), Academic Search Complete (social science and education), and the Web of Science (general science literature). We used search terms to reflect palliative, hospice, supportive, terminal, or end-of-life care for all KQs (Supplemental File: Search Strategy), combined with search terms relevant to each KQ. All searches were limited to English-language publications from 2013 (i.e., after the third edition of the NCP Guidelines was published) to February 2018. In addition, we reference-mined systematic reviews, used existing literature collections, and consulted with content experts.

      Study Selection

      To select studies for inclusion in the review, we applied eligibility criteria determined a priori following a PICOTSS (population, intervention, comparator, outcome, timing, setting, and study design) framework. Population: Eligible populations included patients of all ages with advanced illness and/or if relevant to the KQ, their family members and informal caregivers. Disease-specific (e.g., cancer, heart failure and other cardiac conditions, chronic pulmonary disease, dementia and other neurological conditions, liver disease, or renal disease) and nonspecific studies of advanced, late- or end-stage, or metastatic illness were eligible for inclusion. Identified reviews had to target patients with advanced, late- or end-stage, or metastatic illness and/or describe subgroup analyses of this population to be eligible for inclusion. Intervention: Studies had to report the effects of palliative care interventions on relevant patient and family/caregiver outcomes. Eligibility criteria for types of interventions varied by KQ (Supplemental File). Comparator: Studies had to include a comparator (usual care, waiting list, or other intervention) to be eligible but no other study design criterion for primary research was imposed. Outcome: Eligibility criteria for outcomes varied by KQ (Supplemental File). Timing: Studies could be of any duration and follow-up period. Setting: Reviews had to include studies conducted in U.S. settings to be eligible, although reviews could report on multiple geographic locations. All practice settings (e.g., inpatient, outpatient, home, community) were eligible. Study design: Systematic reviews were eligible for inclusion. Systematic reviews use a resource-intensive approach to identify relevant studies, searching multiple sources with comprehensive search strategies. The reviews appraise the risk of bias of individual studies and assess the study results independently from the original study authors. Systematic reviews often include a meta-analysis that aggregates data across studies to increase statistical power and to obtain an objective effect summary.

      Screening Procedures

      Experienced literature reviewers screened citations identified in the literature searches and trained a machine learning algorithm to identify relevant citations. One reviewer screened all citations; citations identified by the algorithm as potentially relevant were screened by two independent literature reviewers. Titles and abstracts deemed relevant by at least one reviewer were obtained as full-text publications to ensure that no relevant study was missed. Full-text publications were reviewed by two independent reviewers against the explicit eligibility criteria to minimize reviewer errors and bias. Discrepancies were resolved through discussion with the review team.

      Data Abstraction and Critical Appraisal

      From each included review, we abstracted review details (e.g., search dates, settings, number of included studies), participant characteristics, intervention descriptions, relevant results, and authors' conclusions. Where provided (e.g., meta-analyses), we abstracted pooled effect estimates. Data were abstracted in an online database for systematic reviews, using a pilot-tested form with detailed reviewer instructions to ensure standardized and accurate data extraction. Data were abstracted by one literature reviewer and checked for accuracy by an experienced second reviewer. Discrepancies were resolved by team discussion. We used an explicit and transparent approach to assess the methodological quality of included systematic reviews across 11 critical appraisal dimensions: 1) explicitly stated review questions; 2) appropriate inclusion criteria; 3) appropriate search strategy; 4) adequate sources and multiple databases searched; 5) appropriate appraisal criteria; 6) dual appraisal; 7) data abstraction process minimizing errors; 8) appropriate synthesis; 9) publication bias assessment; 10) recommendations supported by data; and 11) appropriate research suggestions. In addition, we considered context-specific criteria such as the applicability of the results to a palliative care review question.

      Synthesis and Quality of Evidence Assessment

      Evidence tables were created to allow a transparent and accessible overview and structure the available study details and results for all included studies. We summarized findings organized by KQ, intervention type, study population/age group (e.g., pediatric vs. adult), setting (e.g., inpatient vs. outpatient), and outcome in a Summary of Findings table. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. The Grading of Recommendations, Assessment, Development and Evaluations framework
      • Atkins D.
      • Best D.
      • Briss P.A.
      • et al.
      Grading quality of evidence and strength of recommendations.
      allows for a transparent overview using internationally accepted criteria to differentiate high, moderate, low, and very low quality of evidence to describe confidence in the findings among studies. We downgraded for study limitations (e.g., no randomized controlled trials contributing to the evidence), inconsistency in results across studies or lack of replication, imprecision (e.g., due to lack of reported effect estimates or imprecise estimates). We used the assessment of the systematic reviews evaluating the evidence base regarding indirectness, publication bias, or other criteria where applicable.

      Results

      Our search identified 3454 citations and we obtained 497 publications as full text (Fig. 1). We identified 139 systematic reviews meeting the inclusion criteria (18–156) and contributing to one or more KQ. All included reviews and their findings are documented in detail in an evidence table in Supplemental File. The methodological quality of the systematic reviews is summarized in a critical appraisal figure in Supplemental File. Key findings are summarized in Summary of Findings Table 1, Summary of Findings Table 2, Summary of Findings Table 3, Summary of Findings Table 4, Summary of Findings Table 5, Summary of Findings Table 6, Summary of Findings Table 7, Summary of Findings Table 8.
      Figure thumbnail gr1
      Fig. 1Systematic review flow diagram. KQ = key question.
      Summary of Findings Table 1Structure and Process of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Interdisciplinary team care

      Pediatric
      0NANA
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: quality of life
      7 SRs
      • Singer A.E.
      • Goebel J.R.
      • Kim Y.S.
      • et al.
      Populations and interventions for palliative and end-of-life care: a systematic review.
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      • Gaertner J.
      • Siemens W.
      • Meerpohl J.J.
      • et al.
      Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis.
      • Holmenlund K.
      • Sjogren P.
      • Nordly M.
      Specialized palliative care in advanced cancer: what is the efficacy? A systematic review.
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      • Phongtankuel V.
      • Meador L.
      • Adelman R.D.
      • et al.
      Multicomponent palliative care interventions in advanced chronic diseases: a systematic review.
      • Taplin S.H.
      • Weaver S.
      • Salas E.
      • et al.
      Reviewing cancer care team effectiveness.
      Seven reviews reported on quality of life outcomes and effects were positive; for example, a 2017 review noted growing support for the utilization of specialist palliative care teams for improving quality of life in advanced illness (SMD 0.16; CI 0.01–0.31; six RCTs) but highlighted important study limitations of included studies.
      • Gaertner J.
      • Siemens W.
      • Meerpohl J.J.
      • et al.
      Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis.
      One review found moderate-quality evidence that the use of a comprehensive early (initiated up to 24 months before death) team-based contact model improved patient quality of life. In another review, specialist palliative care was associated with a small effect on QoL. One review found an association between the number of disciplines included on the interdisciplinary care team and improved quality of life. Another review found that 40% of interventions with a significant effect of quality of life involved a multidisciplinary team. Another review found that interdisciplinary palliative care teams improved quality of life among cancer patients at the end of life. In another review, patient quality of life significantly improved in five of six included studies examining palliative care team interventions for patients with heart failure.
      M (S)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: ACP decisions
      4 SRs
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      • Yang G.M.
      • Neo S.H.
      • Lim S.Z.
      • Krishna L.K.
      Effectiveness of hospital palliative care teams for cancer inpatients: a systematic review.
      • Field R.A.
      • Fritz Z.
      • Baker A.
      • Grove A.
      • Perkins G.D.
      Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.
      Four reviews reported on ACP decisions using different measures but finding positive effects; including a Canadian HTA review that reported that a hospital team–based model has been shown to increase the odds of completing ACPs compared to usual care (OR 1.6; no CI; low-moderate QoE).
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      One review concluded that review by specialist teams at the point of acute deterioration serves as a useful trigger for ACP decisions. Another review found that five of seven included studies examining palliative care team interventions for patients with heart failure showed increased documentation of preferences for care, advance directives, and DNR and end-of-life orders. One review found 12 pre-post studies demonstrating that palliative care team consultation was associated with code status changes and improved disease and prognosis awareness of patients.
      M (Im)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: death at home
      4 SRs
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      • Holmenlund K.
      • Sjogren P.
      • Nordly M.
      Specialized palliative care in advanced cancer: what is the efficacy? A systematic review.
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      • Leclerc B.S.
      • Blanchard L.
      • Cantinotti M.
      • et al.
      The effectiveness of interdisciplinary teams in end-of-life palliative care: a systematic review of comparative studies.
      Four reviews examined the likelihood of dying at home and effects were positive. Two reviews found evidence that the use of a home team–based model increased the odds of having a home death; the Canadian HTA estimated an 89% or more increase based on two RCTs (no CI).
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      Another review also identified a single RCT demonstrating that the use of an interdisciplinary palliative care team increased odds of having a home death. One review found that two of four included studies showed that palliative care team interventions were associated with an increase in death at home compared to in a hospital.
      M (Im)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: satisfaction with care
      3 SRs
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      • Leclerc B.S.
      • Blanchard L.
      • Cantinotti M.
      • et al.
      The effectiveness of interdisciplinary teams in end-of-life palliative care: a systematic review of comparative studies.
      Three reviews found that interdisciplinary team care was associated with statistically significant improvements in patient satisfaction compared to usual care (no effect estimate reported).M (Im)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: physical symptoms
      4 SRs
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      • Holmenlund K.
      • Sjogren P.
      • Nordly M.
      Specialized palliative care in advanced cancer: what is the efficacy? A systematic review.
      • Yang G.M.
      • Neo S.H.
      • Lim S.Z.
      • Krishna L.K.
      Effectiveness of hospital palliative care teams for cancer inpatients: a systematic review.
      • Leclerc B.S.
      • Blanchard L.
      • Cantinotti M.
      • et al.
      The effectiveness of interdisciplinary teams in end-of-life palliative care: a systematic review of comparative studies.
      Four reviews found evidence that the use of an interdisciplinary palliative care team was associated with improvements in symptom management and physical comfort and reduced physical symptoms but effect estimates were not reported and effects varied by study and outcome.L (Im, In)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Patient outcome: psychological symptoms
      4 SRs
      • Singer A.E.
      • Goebel J.R.
      • Kim Y.S.
      • et al.
      Populations and interventions for palliative and end-of-life care: a systematic review.
      • Kassianos A.P.
      • Ioannou M.
      • Koutsantoni M.
      • Charalambous H.
      The impact of specialized palliative care on cancer patients' health-related quality of life: a systematic review and meta-analysis.
      • Holmenlund K.
      • Sjogren P.
      • Nordly M.
      Specialized palliative care in advanced cancer: what is the efficacy? A systematic review.
      • Leclerc B.S.
      • Blanchard L.
      • Cantinotti M.
      • et al.
      The effectiveness of interdisciplinary teams in end-of-life palliative care: a systematic review of comparative studies.
      Four reviews found mostly positive effects but reported on different psychological outcomes and none reported an effect estimate. One review found that case management, palliative care teams, hospice, skills training, and other interventions were all effective on patient depressive symptoms, indicated by 12 studies. Another review noted moderate evidence that specialist palliative care teams reduce psychological symptoms. A third review found that use of an interdisciplinary palliative care team was associated with reduced anxiety and depression. One review identified one RCT showing no difference in emotional burden associated with interdisciplinary care teams.L (Im, In)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Family/caregiver outcome: satisfaction with care
      1 SR
      • Health Quality O.
      Team-based models for end-of-life care: an evidence-based analysis.
      A Canadian HTA review reported moderate-quality evidence that the use of a comprehensive, direct, and early team-based contact model initiated up to nine months before death improved informal caregiver satisfaction but provided no effect estimate.M (Im)
      Interdisciplinary team care

      Adults or mixed samples

      Multiple settings

      Family/caregiver outcome: psychological symptoms
      1 SR
      • Singer A.E.
      • Goebel J.R.
      • Kim Y.S.
      • et al.
      Populations and interventions for palliative and end-of-life care: a systematic review.
      One review found that interventions with a significant effect on caregiver depressive symptoms (12 studies) often involved a home component, did not use multidisciplinary teams, were long-term, and often involved caregiver skills training or counseling and therapy but did not report effect estimates.L (Im, In)
      Interdisciplinary team care

      Adults or mixed samples

      ICU

      Patient outcome: mortality
      2 SRs
      • Martins B.
      • Oliveira R.A.
      • Cataneo A.J.M.
      Palliative care for terminally ill patients in the intensive care unit: systematic review and metaanalysis.
      • Aslakson R.
      • Cheng J.
      • Vollenweider D.
      • et al.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      Two reviews came to different conclusions: one review found that ICU-based palliative care team interventions did not change hospital mortality; however, another review found that the introduction of palliative care teams can reduce mortality rates in the ICU.V (S, In, Im)
      Interdisciplinary team care

      Adults or mixed samples

      ICU

      Family/caregiver outcome: satisfaction with care
      1 SR
      • Aslakson R.
      • Cheng J.
      • Vollenweider D.
      • et al.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      One review found that ICU-based palliative care team interventions did not change family/caregiver satisfaction with care.V (S, Im, In)
      Interdisciplinary team care

      Adults or mixed samples

      ICU

      Family/caregiver outcome: ACP
      1 SR
      • Aslakson R.
      • Cheng J.
      • Vollenweider D.
      • et al.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      One review found that ICU-based palliative care team interventions statistically significantly decreased nonconsensus between family members and providers but did not report an effect estimate.L (Im)
      Interdisciplinary team care

      Adults or mixed samples

      ICU

      Family/caregiver: psychological symptoms
      1 SR
      • Aslakson R.
      • Cheng J.
      • Vollenweider D.
      • et al.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      One review found that ICU-based palliative care team interventions statistically significantly decreased family member PTSD and anxiety but the result was based on a single study.L (Im, In)
      Telehealth

      Adults and pediatrics

      Setting: home/outpatient

      Patient outcome: quality of life
      2 SRs
      • Bradford N.
      • Armfield N.R.
      • Young J.
      • Smith A.C.
      The case for home based telehealth in pediatric palliative care: a systematic review.
      • Gilbertson-White S.
      • Saeidzadeh S.
      • Yeung C.W.
      • Tykol H.
      • Vikas P.
      Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer.
      Two reviews found that quality of life and well-being may be affected positively by telehealth interventions but neither reported an effect estimate, study results varied, and no summary was reported.L (Im, In)
      Telehealth

      Adults

      Setting: home/outpatient

      Patient outcome: quality of life
      2 SRs
      • Bakitas M.A.
      • Elk R.
      • Astin M.
      • et al.
      Systematic review of palliative care in the rural setting.
      • Head B.A.
      • Schapmire T.J.
      • Zheng Y.Q.
      Telehealth in palliative care a systematic review of patient-reported outcomes.
      • Gilbertson-White S.
      • Saeidzadeh S.
      • Yeung C.W.
      • Tykol H.
      • Vikas P.
      Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer.
      Two reviews reported quality of life outcomes and reported mixed evidence. One review identified a single RCT demonstrating a significant improvement in quality of life compared to usual care. Another review found that although overall evidence for palliative telehealth is weak, there is potential for some telehealth interventions to support patients' quality of life but the review reported no effect estimate.L (Im, In)
      Telehealth

      Adults

      Setting: home/outpatient

      Patient outcome: physical symptoms
      2 SRs
      • Head B.A.
      • Schapmire T.J.
      • Zheng Y.Q.
      Telehealth in palliative care a systematic review of patient-reported outcomes.
      • Gilbertson-White S.
      • Saeidzadeh S.
      • Yeung C.W.
      • Tykol H.
      • Vikas P.
      Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer.
      Two reviews addressed physical symptoms and found mixed evidence but did not report effect estimates. One review identified observable but nonsignificant reductions in physical symptoms associated with telehealth but did not report an effect estimate. One review found that although overall evidence for palliative telehealth is weak, some telehealth interventions can aid in physical symptom control.L (Im, In)
      Telehealth

      Adults and pediatrics

      Setting: home/outpatient

      Patient outcome: psychological health
      4 SRs
      • Bakitas M.A.
      • Elk R.
      • Astin M.
      • et al.
      Systematic review of palliative care in the rural setting.
      • Bradford N.
      • Armfield N.R.
      • Young J.
      • Smith A.C.
      The case for home based telehealth in pediatric palliative care: a systematic review.
      • Head B.A.
      • Schapmire T.J.
      • Zheng Y.Q.
      Telehealth in palliative care a systematic review of patient-reported outcomes.
      • Gilbertson-White S.
      • Saeidzadeh S.
      • Yeung C.W.
      • Tykol H.
      • Vikas P.
      Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer.
      Four reviews addressed psychological health including anxiety and reported positive results but none provided an effect estimate. One review concluded that anxiety may be affected positively by telehealth interventions, while another review identified improvements in emotional symptoms including anxiety, depression, PTSD, and negative affect. One more review identified improvements in anxiety, depression, and distress. Another review identified two RCTs demonstrating significant improvements in depression.M (Im)
      Telehealth

      Adults and pediatrics

      Setting: home/outpatient

      Patient outcome: resource use
      1 SR
      • Bradford N.
      • Armfield N.R.
      • Young J.
      • Smith A.C.
      The case for home based telehealth in pediatric palliative care: a systematic review.
      One review included a study demonstrating a 60% reduction in hospital admissions was associated with telehealth.V (S, Im, In)
      Telehealth

      Adults

      Setting: home/outpatient

      Patient outcome: resource use
      1 SR
      • Head B.A.
      • Schapmire T.J.
      • Zheng Y.Q.
      Telehealth in palliative care a systematic review of patient-reported outcomes.
      One review found that telehealth interventions can reduce unnecessary/avoidable utilization but the review reported no effect estimate.L (Im)
      Telehealth

      Adults

      Setting: home/outpatient

      Patient outcome: satisfaction with care
      2 SRs
      • Head B.A.
      • Schapmire T.J.
      • Zheng Y.Q.
      Telehealth in palliative care a systematic review of patient-reported outcomes.
      • Gilbertson-White S.
      • Saeidzadeh S.
      • Yeung C.W.
      • Tykol H.
      • Vikas P.
      Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer.
      Two reviews identified positive impacts of telehealth on increasing satisfaction with the telehealth intervention but reported no effect estimate.L (Im, In)
      Telehealth

      Adults and pediatrics

      Setting: home/outpatient

      Family/caregiver outcome: quality of life
      1 SR
      • Bradford N.
      • Armfield N.R.
      • Young J.
      • Smith A.C.
      The case for home based telehealth in pediatric palliative care: a systematic review.
      One review found that family/caregiver quality of life may be affected positively by telehealth interventions but the review reported no effect estimate.L (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: quality of life
      2 SRs
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      • Tassinari D.
      • Drudi F.
      • Monterubbianesi M.C.
      • et al.
      Early palliative care in advanced oncologic and non-oncologic chronic diseases: a systematic review of literature.
      Two reviews addressed quality of life but conclusions varied. One review concluded on the basis of three RCTs and one quasi-experimental study all demonstrating significant improvements in quality of life that there is robust evidence that early palliative care integrated into standard oncology care significantly improves quality of life. Another review noted that two of seven RCTs reported improved quality of life while the remaining four RCTs and one prospective cohort study reported no difference.L (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: quality of life
      3 SRs
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      Three reviews addressed early/integrated care in home/outpatient settings and reported mixed evidence, including a Cochrane review that reported a positive effect (SMD 0.27; CI 0.15, 0.38; low QoE) compared to usual care.
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      A second review concluded that early/integrated palliative care may be slightly better than usual care at improving quality of life and another review reported mixed evidence on the impact of early/integrated palliative care (no effect estimates).
      L (S, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: physical symptoms
      4 SRs
      • Kim S.L.
      • Tarn D.M.
      Effect of primary care involvement on end-of-life care outcomes: a systematic review.
      • Carmont S.A.
      • Mitchell G.
      • Senior H.
      • Foster M.
      Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care.
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      • Tassinari D.
      • Drudi F.
      • Monterubbianesi M.C.
      • et al.
      Early palliative care in advanced oncologic and non-oncologic chronic diseases: a systematic review of literature.
      Four systematic reviews addressed physical symptoms and identified mixed evidence but none reported an effect estimate. One review concluded that integrated palliative care could help maintain functional status; another review identified a single study demonstrating improvements in physical symptoms. Another review identified mixed evidence regarding the impact of integrated care on symptom management. One review found one RCT reporting partially improved symptoms control and four RCTs reporting no difference.L (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: physical symptoms
      3 SRs
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      Three reviews addressed physical symptoms in home/outpatient settings and reported mixed evidence, including a Cochrane review that reported a statistically significant reduction (SMD −0.23; CI −0.35, −0.10; seven studies; low QoE).
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      Two reviews reported mixed evidence on the impact of early/integrated palliative care on physical symptoms and did not report effect estimates.
      L (S, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: depression
      1 SR
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      One review reported there is robust evidence that early palliative care reduces depression but did not report an effect estimate.L (Im)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: psychological health
      3 SRs
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      Three reviews reported on home/outpatient settings and identified mixed evidence, including a Cochrane review that reported no statistically significant difference for depression (SMD −0.11; CI −0.26, 0.03; five RCTs; very low QoE)
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      and another review that reported some evidence that early/integrated palliative care is associated with improvements in depression. Another review reported mixed evidence on the impact of early/integrated care on depression and anxiety.
      V (S, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: mortality
      2 SRs
      • Kim S.L.
      • Tarn D.M.
      Effect of primary care involvement on end-of-life care outcomes: a systematic review.
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      Two reviews addressed mortality but the effect of early/integrated palliative care is unclear. One review found mixed evidence on the impact of early/integrated palliative care on survival, with some studies reporting improvements in survival associated with integrated care, and other studies reporting nonsignificant or no improvements in survival. Another review included a study that found integrated primary care for patients with cancer provided no advantage over cancer care alone.V (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: mortality
      2 SRs
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      Two reviews reported on mortality in outpatient settings and found unclear evidence on the effect of early/integrated palliative care. A 2017 Cochrane review reported no difference across treatment arms (HR 0.85; CI 0.56, 1.28; four RCTs; very low QoE)
      • Haun M.W.
      • Estel S.
      • Rucker G.
      • et al.
      Early palliative care for adults with advanced cancer.
      and another review reported mixed evidence but did not report an effect estimate.
      V (S, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: rehospitalization
      2 SRs
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      • Carpenter J.G.
      Hospital palliative care teams and post-acute care in nursing facilities: an integrative review.
      Two reviews addressed integrated care and rehospitalizations and found mixed evidence. One review (based on a search in one database only) reported a positive effect estimate for heart failure patients (RR 0.58; CI 0.44, 0.77; three RCTs)
      • Diop M.S.
      • Rudolph J.L.
      • Zimmerman K.M.
      • Richter M.A.
      • Skarf L.M.
      Palliative care interventions for patients with heart failure: a systematic review and meta-analysis.
      but a second review noted mixed results regarding associations of outpatient palliative care with a reduction in hospital admissions and rehospitalization.
      L (S, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: resource use
      5 SRs
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      • Carmont S.A.
      • Mitchell G.
      • Senior H.
      • Foster M.
      Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care.
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      • Kirolos I.
      • Tamariz L.
      • Schultz E.A.
      • et al.
      Interventions to improve hospice and palliative care referral: a systematic review.
      Several reviews addressed resource use but results varied across and within reviews and measures and only one review reported effect estimates (appropriate use of care SMD 0.37; CI 0.29, 0.45; six studies; utilization reduced SMD 0.22; CI −0.05, 0.49; four studies).
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      One review concluded that integrated palliative care can reduce hospitalizations. One review found that integrated care leads to reduced ED, hospital and acute care visits, and decreased hospital length of stay. Another review found that integrated care was associated with increased hospice referrals. However, two reviews found no difference between integrated and usual care in terms of health care use and hospital length of stay.
      V (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: resource use
      2 SRs
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      Two reviews reported mixed evidence on the impact of early/integrated palliative care on resource utilization including ED admissions, hospital length of stay, and use of aggressive care at the end of life.L (Im, In)
      Early/integrated palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: satisfaction with care
      1 SR
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      One review noted that early/integrated palliative care was found to be associated with increased satisfaction with care in a majority of studies but did not report an effect estimate.L (Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: mixed

      Patient outcome: ACP
      1 SR
      • Kirolos I.
      • Tamariz L.
      • Schultz E.A.
      • et al.
      Interventions to improve hospice and palliative care referral: a systematic review.
      One review found early palliative care improved goals of care discussion and advance care planning.L (S, Im)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: ACP
      2 SRs
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      Two reviews reported mixed evidence on the impact of early palliative care on advance care planning. One review reported increased advanced directives associated with early/integrated palliative care while another review found no significant impact of early/integrated care on advance care planning.L (Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: mixed

      Family/caregiver: quality of life
      4 SRs
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      Four reviews reported on family quality of life but results varied across and within reviews. One review found mixed evidence while another review found no difference between groups on the impact of early/integrated care on family/caregiver quality of life (none provided an effect estimate). One review reported that some RCTs testing early palliative care in various settings and populations found improved caregiver burden and better maintenance of caregiver quality of life. One review found no evidence on significant impact of early/integrated palliative care on family/caregiver quality of life.L (Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: mixed

      Family/caregiver: psychological health
      1 SR
      • Ferrell B.R.
      • Temel J.S.
      • Temin S.
      • et al.
      Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.
      One review found mixed evidence for the impact of early/integrated care on family/caregiver psychological symptoms and well-being.V (S, Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Family/caregiver: psychological health
      1 SR
      • Cunningham C.
      • Travers K.
      • Chapman R.
      • et al.
      Palliative Care in the Outpatient Setting.
      One review noted that early/integrated palliative care was associated with reductions in depressive symptoms in one study but did not report an effect estimate.L (Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: mixed

      Family/caregiver: satisfaction with care
      1 SR
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      One review found no difference in satisfaction with care after the implementation of an early/integrated care intervention.V (S, Im)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Family/caregiver: satisfaction with care
      1 SR
      • Davis M.P.
      • Temel J.S.
      • Balboni T.
      • Glare P.
      A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses.
      One review reported that some RCTs testing early palliative care in various settings and populations found improved family satisfaction.L (Im, In)
      Early/integrative palliative care

      Adults or mixed samples

      Setting: mixed

      Family/caregiver: ACP
      1 SR
      • Carpenter J.G.
      Hospital palliative care teams and post-acute care in nursing facilities: an integrative review.
      One review concluded that continuous palliative care after discharge may result in greater advance care planning communication, based on findings from a pilot study.V (S, Im, In)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: death at home
      2 SRs
      • Shepperd S.
      • Goncalves-Bradley D.C.
      • Straus S.E.
      • Wee B.
      Hospital at home: home-based end-of-life care.
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      Two reviews reported on dying at home as an outcome of home-based palliative care and both were positive. One review found that patients in home-based palliative care were more likely to die at home compared to usual care (OR 2.21; CI 1.31, 3.71; five RCTs, two CCTs).
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      Another review found a similar significant association (RR 1.33; CI 1.14, 1.55; three RCTs).
      • Shepperd S.
      • Goncalves-Bradley D.C.
      • Straus S.E.
      • Wee B.
      Hospital at home: home-based end-of-life care.
      H
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: physical symptoms
      1 SR
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      One review found three RCTs reporting a strong positive effect of home palliative care on symptom burden; nine RCTs reporting mixed evidence regarding the effect of home palliative care on pain improvement; and five RCTs reporting mixed evidence on the effect of home palliative care on physical function; concluding that evidence for home-based palliative care for improving pain and physical function is inconclusive but that evidence for reducing symptom burden is reliable and clear.L (In, Im)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: quality of life
      1 SR
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      One review concluded that evidence is inconclusive regarding the effect of home palliative care on patient quality of life, on the basis of three RCTs reporting no significant effects and two RCTs reporting significant effects.L (In, Im)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: satisfaction
      2 SRs
      • Shepperd S.
      • Goncalves-Bradley D.C.
      • Straus S.E.
      • Wee B.
      Hospital at home: home-based end-of-life care.
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      Two reviews examined the effect of home palliative care on patient satisfaction and reported mixed results. One review noted that evidence regarding satisfaction with care is conflicting; three RCTs found significant positive effects but two RCTs reported no significant between-group differences. Another review found two RCTs demonstrating small increases in satisfaction for patients receiving end-of-life care at home reported at one month.L (Im, In)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Patient outcome: resource use
      1 SR
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      One review found six RCTs showing moderate evidence on no significant effect of home-based palliative care on ED visits.M (Im)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Family/caregiver outcome: caregiver burden
      2 SRs
      • Shepperd S.
      • Goncalves-Bradley D.C.
      • Straus S.E.
      • Wee B.
      Hospital at home: home-based end-of-life care.
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      Two reviews found conflicting evidence on the positive impact of home palliative care on caregiver burden.L (Im, In)
      Home-based palliative care

      Adults or mixed samples

      Setting: home/outpatient

      Family/caregiver outcome: satisfaction
      1 SR
      • Gomes B.
      • Calanzani N.
      • Curiale V.
      • McCrone P.
      • Higginson I.J.
      Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
      One review found one controlled before-after study found significantly higher satisfaction with care among caregivers in the hospital-based intervention versus home care.V (S, Im, In)
      Case management

      Adults or mixed samples

      Setting: mixed

      Patient outcome: resource use
      1 SR
      • Thomas R.E.
      • Wilson D.M.
      • Birch S.
      • Woytowich B.
      Examining end-of-life case management: systematic review.
      One review found mixed low-quality evidence on the impact of case management on hospital utilization at the end of life.V (S, Im, In)
      Case management

      Adults or mixed samples

      Setting: mixed

      Patient outcome: physical symptoms
      1 SR
      • Thomas R.E.
      • Wilson D.M.
      • Birch S.
      • Woytowich B.
      Examining end-of-life case management: systematic review.
      One review found evidence on the positive impact of case management on reducing symptom distress, including one RCT, but no effect estimates were reported.L (Im)
      Care coordination/coordinators

      Adults or mixed samples

      Setting: mixed

      Patient outcome: quality of life
      1 SR
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      One review found no statistically significant effects of care coordination/coordinators on quality of life in cancer patients (g = 0.12; CI −0.01, 0.26; five studies).
      • Gorin S.S.
      • Haggstrom D.
      • Han P.K.J.
      • et al.
      Cancer care coordination: a systematic review and meta-analysis of over 30 years of empirical studies.
      L (S)
      N = number of systematic reviews; NA = not applicable; SR = systematic review; SMD = standardized mean difference; CCT = controlled clinical trial(s); RCT(s) = randomized controlled trial(s); QoL = quality of life; M = moderate quality of evidence; S = study limitation; ACP = advance care planning; HTA = health technology assessment; OR = odds ratio; QoE = quality of evidence; DNR = do-not-resuscitate; Im = imprecision; L = low quality of evidence; In = inconsistency; ICU = intensive care unit; V = very low quality of evidence; PTSD = post-traumatic stress disorder; RR = risk ratio; ED = emergency department; H = high quality of evidence.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 2Physical Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Pharmacological interventions for pain

      Pediatrics only

      Outcome: pain management
      1 SR
      • Beecham E.
      • Candy B.
      • Howard R.
      • et al.
      Pharmacological interventions for pain in children and adolescents with life-limiting conditions.
      One review found mixed evidence on the impact of pharmacological interventions for pain in pediatric populations. The review identified two RCTs where intrathecal baclofen was significantly associated with an improvement in pain among children with cerebral palsy, two RCTs where botulinum was not associated with improvements in pain in the same population, and three trials with mixed evidence on the positive impact of alendronate/risedronate for pain in osteogenesis imperfecta. The review did not report effect estimates.L (Im, In)
      Comprehensive palliative care

      Adults and mixed samples

      Outcome: symptom burden
      1 SR
      • Kavalieratos D.
      • Corbelli J.
      • Zhang D.
      • et al.
      Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis.
      One review found that comprehensive palliative care was associated with a statistically and clinically significant reduction in symptom burden in adults with advanced illness at one- to three-month follow-up (SMD −0.66; CI −1.25, −0.07; 10 RCTs) and at four- to six-month follow-up (SMD −0.31; CI −0.05, −0.07; six RCTs;
      • Kavalieratos D.
      • Corbelli J.
      • Zhang D.
      • et al.
      Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis.
      however, the review noted extremely high heterogeneity across identified studies.
      M (S)
      Pharmacological interventions

      Adults and mixed samples

      Outcome: pain management
      8 SRs
      • Mercadante S.
      • Bruera E.
      Methadone as a first-line opioid in cancer pain management: a systematic review.
      • Ahn J.S.
      • Lin J.
      • Ogawa S.
      • et al.
      Transdermal buprenorphine and fentanyl patches in cancer pain: a network systematic review.
      • Pace A.
      • Dirven L.
      • Koekkoek J.A.F.
      • et al.
      European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma.
      • Husebo B.S.
      • Achterberg W.
      • Flo E.
      Identifying and managing pain in people with Alzheimer's disease and other types of dementia: a systematic review.
      • van den Beuken-van Everdingen M.H.
      • de Graeff A.
      • Jongen J.L.
      • et al.
      Pharmacological treatment of pain in cancer patients: the role of adjuvant analgesics, a systematic review.
      • Porta-Sales J.
      • Garzon-Rodriguez C.
      • Llorens-Torrome S.
      • et al.
      Evidence on the analgesic role of bisphosphonates and denosumab in the treatment of pain due to bone metastases: a systematic review within the European Association for Palliative Care guidelines project.
      • Bausewein C.
      • Simon S.T.
      • Pralong A.
      • et al.
      Palliative care of adult patients with cancer.
      Eight reviews reported pain management outcomes associated with various pharmacological interventions but effects varied by study and outcome. Transdermal buprenorphine and transdermal fentanyl demonstrate equivalent analgesic efficacy in patients with cancer pain. There is limited evidence for the efficacy of metamizole in treating cancer pain. One review concluded that levomepromazine is completely or partially effective at managing pain. One review reported a lack of data to support a net conclusion but noted that methadone is a first-choice opioid for treating cancer pain. There is limited evidence as to the effect of using paracetamol and morphine to treat pain among people with dementia. Among adult patients with glioma, dexamethasone once a day is the preferred corticosteroid for pain control, though one review noted that nonsteroidal anti-inflammatory drugs (NSAIDS), analgesics, and coanalgesics should also be considered in the treatment of headache in patients with primary brain tumors. Among adult patients with metastatic bone pain, one review concluded that the use of bisphosphonates and denosumab for direct pain relief is weak. Similarly, another review concluded that there is no or very low-quality evidence to support the use of adjuvant analgesics in patients with metastatic bone pain. None of the reviews reported effect estimates.L (Im, In)
      Pharmacological interventions

      Adults and mixed samples

      Outcome: nausea/vomiting
      4 SRs
      • Vayne-Bossert P.
      • Haywood A.
      • Good P.
      • et al.
      Corticosteroids for adult patients with advanced cancer who have nausea and vomiting (not related to chemotherapy, radiotherapy, or surgery).
      • Murray-Brown F.
      • Dorman S.
      Haloperidol for the treatment of nausea and vomiting in palliative care patients.
      • McLean S.L.
      • Blenkinsopp A.
      • Bennett M.I.
      Using haloperidol as an antiemetic in palliative care: informing practice through evidence from cancer treatment and postoperative contexts.
      • Dietz I.
      • Schmitz A.
      • Lampey I.
      • Schulz C.
      Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review.
      Four reviews reported nausea/vomiting outcomes, with mixed evidence on the benefits of pharmacological interventions. A 2017 Cochrane review found very low-quality evidence that neither supported nor refuted corticosteroid use for nausea/vomiting among patients with advanced cancer (SMD 0.48; CI −1.53, 0.57; two RCTs).
      • Vayne-Bossert P.
      • Haywood A.
      • Good P.
      • et al.
      Corticosteroids for adult patients with advanced cancer who have nausea and vomiting (not related to chemotherapy, radiotherapy, or surgery).
      Another review concluded that levomepromazine is completely or partially effective at managing nausea/vomiting. Two reviews concluded there is insufficient direct evidence to definitively support the use of haloperidol for the management of nausea and vomiting.
      V (S, Im, In)
      Pharmacological interventions

      Adults and mixed samples

      Outcome: dyspnea management
      5 SRs
      • Barnes H.
      • McDonald J.
      • Smallwood N.
      • Manser R.
      Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness.
      • Bausewein C.
      • Simon S.T.
      • Pralong A.
      • et al.
      Palliative care of adult patients with cancer.
      • Vargas-Bermudez A.
      • Cardenal F.
      • Porta-Sales J.
      Opioids for the management of dyspnea in cancer patients: evidence of the last 15 Years–a systematic review.
      • Bajwah S.
      • Ross J.R.
      • Peacock J.L.
      • et al.
      Interventions to improve symptoms and quality of life of patients with fibrotic interstitial lung disease: a systematic review of the literature.
      • Boyden J.Y.
      • Connor S.R.
      • Otolorin L.
      • et al.
      Nebulized medications for the treatment of dyspnea: a literature review.
      Five reviews reported on dyspnea outcomes with mixed evidence on the benefits of pharmacological interventions. A 2016 Cochrane review concluded there is some low-quality evidence that shows the ability for oral or parenteral opioids to palliate breathlessness although the number of included participants was small (change from baseline SMD −0.09; CI −0.36, 0.19; P = 0.54; seven studies; post-treatment SMD 0.28; CI −0.50, −0.05; P = 0.02; 11 studies).
      • Barnes H.
      • McDonald J.
      • Smallwood N.
      • Manser R.
      Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness.
      Another review found evidence for opioids for improving breathlessness among patients with advanced cancer. One review reported evidence that some opioids are effective at treating dyspnea in advanced cancer patients and that benzodiazepines showed no significant benefit at treating dyspnea. One review concluded there is evidence from weak study designs for improvements in dyspnea after administration of diamorphine. Another review reported potential benefits for using nebulized furosemide, hydromorphone, and fentanyl to treat dyspnea, but mixed evidence for nebulized morphine.
      L (S)
      Pharmacological interventions

      Adults and mixed samples

      Outcome: constipation
      2 SRs
      • Pedrosa Carrasco A.J.
      • Timmermann L.
      • Pedrosa D.J.
      Management of constipation in patients with Parkinson's disease.
      • Tuffaha M.G.H.
      • Al-Atiyyat N.
      Methylnaltrexone or laxatives for the management OF OPIOID-INDUCED constipation among palliative patients ON opioid therapy: EVIDENCE-based review.
      Two reviews reported constipation-related outcomes of pharmacological interventions but did not report effect estimates and found mixed evidence. One review found several RCTs supporting the use of dietetic interventions with probiotics and prebiotics for relieving symptoms of constipation, and mixed evidence supporting the use of lubiprostone, macrogol, and injections of botulinum neurotoxin A for outlet obstruction constipation. Another review found six RCTs and concluded that evidence supporting the use of laxatives such as lactulose and senna for management of constipation was uncertain but that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation.L (Im, In)
      Cannabinoids

      Adults and mixed samples

      Outcome: pain management
      1 SR
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      One review found two trials reporting trends toward improvements in cancer-related pain associated with cannabinoids (SMD 0.07; CI −0.01, 0.16; two RCTs).
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      L (In)
      Cannabinoids

      Adults and mixed samples

      Outcome: nausea/vomiting
      1 SR
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      A single review found one trial reporting nonsignificant improvements in cancer-related nausea and vomiting, while another trial found no effects (SMD 0.21; CI 0.10, 0.52; two RCTs).
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      L (In)
      Radiation/chemotherapy

      Adults and mixed samples

      Outcome: pain management
      12 SRs
      • Pin Y.
      • Paix A.
      • Le Fevre C.
      • et al.
      A systematic review of palliative bone radiotherapy based on pain relief and retreatment rates.
      • Park K.R.
      • Lee C.G.
      • Tseng Y.D.
      • et al.
      Palliative radiation therapy in the last 30 days of life: a systematic review.
      • Tey J.
      • Soon Y.Y.
      • Koh W.Y.
      • et al.
      Palliative radiotherapy for gastric cancer: a systematic review and meta-analysis.
      • Chow R.
      • Hoskin P.
      • Hollenberg D.
      • et al.
      Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis.
      • Chow R.
      • Hoskin P.
      • Chan S.
      • et al.
      Efficacy of multiple fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review.
      • Lutz S.
      • Balboni T.
      • Jones J.
      • et al.
      Palliative radiation therapy for bone metastases: update of an ASTRO Evidence-Based Guideline.
      • Jong J.M.
      • Oprea-Lager D.E.
      • Hooft L.
      • et al.
      Radiopharmaceuticals for palliation of bone pain in patients with castration-resistant prostate cancer metastatic to bone: a systematic review.
      • Ma J.T.
      • Zheng J.H.
      • Han C.B.
      • Guo Q.Y.
      Meta-analysis comparing higher and lower dose radiotherapy for palliation in locally advanced lung cancer.
      • Cameron M.G.
      • Kersten C.
      • Vistad I.
      • Fossa S.
      • Guren M.G.
      Palliative pelvic radiotherapy of symptomatic incurable rectal cancer - a systematic review.
      • Wong E.
      • Hoskin P.
      • Bedard G.
      • et al.
      Re-irradiation for painful bone metastases - a systematic review.
      • Cameron M.G.
      • Kersten C.
      • Guren M.G.
      • Fossa S.D.
      • Vistad I.
      Palliative pelvic radiotherapy of symptomatic incurable prostate cancer - a systematic review.
      • Dennis K.
      • Makhani L.
      • Zeng L.
      • Lam H.
      • Chow E.
      Single fraction conventional external beam radiation therapy for bone metastases: a systematic review of randomised controlled trials.
      Twelve reviews reported pain management outcomes related to radiation and/or chemotherapy intervention; effects varied by study and outcome. One review concluded that palliative RT was effective at improving pain and that low regimens appear to be adequate for symptom palliation. Two reviews concluded that single-fraction and multifraction schedules held equivalent effectiveness for pain relief, while another review found greater use of shorter or single-fraction regimens may be beneficial, especially in patients with poor performance status. One review concluded that there was no difference in pain response across multiple fraction radiotherapy doses. One review concluded there was no significant difference in palliation of chest pain between higher and lower RT doses (combined OR 1.83; CI 0.76, 4.38; P = 0.176; three RCTs).
      • Ma J.T.
      • Zheng J.H.
      • Han C.B.
      • Guo Q.Y.
      Meta-analysis comparing higher and lower dose radiotherapy for palliation in locally advanced lung cancer.
      One review found that 10 and 6 Gy may produce superior pain response compared to 8 Gy, and 6 Gy may result in better partial response than 8 Gy, but noted that only a few studies documented doses other than 8 Gy. Similarly, another review concluded that 8 Gy should be the standard dose against which future treatments are compared due to its reproducible pain response rate and its established safe profile. Another review concluded that the efficacy of re-irradiation is comparable to initial radiation treatment. One review concluded that palliative pelvic RT was effective at relieving pain in rectal cancer (pooled positive response across 23 studies: 78%) but noted there is considerable heterogeneity in treatments and outcomes across studies.
      • Cameron M.G.
      • Kersten C.
      • Vistad I.
      • Fossa S.
      • Guren M.G.
      Palliative pelvic radiotherapy of symptomatic incurable rectal cancer - a systematic review.
      One review found positive impact of radionuclides on pain relief.
      L (In, Im)
      Cementoplasty/kyphoplasty/vertebroplasty

      Adults and mixed samples

      Outcome: pain management
      2 SRs
      • Mercadante S.
      • Bruera E.
      Methadone as a first-line opioid in cancer pain management: a systematic review.
      • Cazzato R.L.
      • Palussiere J.
      • Buy X.
      • et al.
      Percutaneous long bone cementoplasty for palliation of malignant lesions of the limbs: a systematic review.
      Two reviews reported largely positive pain outcomes related to cementoplasty and related interventions but neither review provided effect estimates. One review concluded that percutaneous long bone cementoplasty is safe and offers good pain relief based on data from 10 non-RCT studies; another review found one RCT supporting the use of kyphoplasty for pain relief in patients with vertebral tumors or metastases.L (S, Im)
      Education/self-management

      Adults and mixed samples

      Outcome: pain management
      2 SRs
      • Nevis I.
      Educational intervention in end-of-life care: an evidence-based analysis.
      • Martinez K.A.
      • Aslakson R.A.
      • Wilson R.F.
      • et al.
      A systematic review of health care interventions for pain in patients with advanced cancer.
      Two reviews reported pain outcomes and found uncertain evidence on the effect of education and self-management interventions. One review found mixed moderate-quality evidence on the effectiveness of combining multiple educational modalities to improve patient pain; however, another review found two studies that reported no significant improvements in pain control after provider educational interventions. Neither review provided effect estimates.L (Im, In)
      Physical therapy/exercise

      Adults and mixed samples

      Outcome: pain management
      1 SR
      • Putt K.
      • Faville K.A.
      • Lewis D.
      • et al.
      Role of physical therapy intervention in patients with life-threatening illnesses.
      One review concluded that physical therapy in palliative care can decrease musculoskeletal pain.L (S, Im)
      Physical therapy/exercise

      Adults and mixed samples

      Outcome: physical function
      2 SRs
      • Dittus K.L.
      • Gramling R.E.
      • Ades P.A.
      Exercise interventions for individuals with advanced cancer: a systematic review.
      • Putt K.
      • Faville K.A.
      • Lewis D.
      • et al.
      Role of physical therapy intervention in patients with life-threatening illnesses.
      Two reviews examined physical function outcomes; evidence suggests that physical therapy in palliative care and other exercise-based interventions can improve physical function in patients with advanced illness, though outcome measures varied widely across studies where physical function was the primary outcome.L (Im, In)
      Exercise

      Adults and mixed samples

      Outcome: dyspnea management
      1 SR
      • Dittus K.L.
      • Gramling R.E.
      • Ades P.A.
      Exercise interventions for individuals with advanced cancer: a systematic review.
      A single review found one RCT and two non-RCTs that showed exercise interventions improved dyspnea but did not provide effect estimates.L (Im, In)
      Music/art therapy

      Adults and mixed samples

      Outcome: pain management
      3 SRs
      • Schmid W.
      • Rosland J.H.
      • von Hofacker S.
      • Hunskar I.
      • Bruvik F.
      Patient's and health care provider's perspectives on music therapy in palliative care - an integrative review.
      • McConnell T.
      • Scott D.
      • Porter S.
      Music therapy for end-of-life care: an updated systematic review.
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Three reviews reported pain management outcomes related to music/art therapies and all reported positive effects on pain management, while acknowledging differences across studies in control groups and pain assessment tools. One review found that exposure to creative arts and music therapies is shown to reduce pain postintervention compared to no treatment, waiting list, usual care, or placebo controls (SMD 0.54; CI 0.33, 0.75; 18 RCTs) and at follow-up (SMD 0.59; CI 0.41, 0.77; seven RCTs).
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Another review found that music therapy was associated with a significant reduction in pain compared to comfort measures, a volunteer visit, or standard care only but noted a high risk of bias among included studies (SMD −0.42; CI −0.68, −0.17; three non-RCT studies).
      • McConnell T.
      • Scott D.
      • Porter S.
      Music therapy for end-of-life care: an updated systematic review.
      Another review found that five of seven studies reported a significant decrease in pain associated with music therapy compared to standard care or extra interventions such as volunteer visits and verbal relaxation exercises.
      Moderate
      Nonpharmacological physical (oxygen, cool air, yoga)

      Adults and mixed samples

      Outcome: pain management
      1 SR
      • Hokka M.
      • Kaakinen P.
      • Polkki T.
      A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer.
      One review examining different modalities such as massage, aromatherapy, TENS, acupuncture, and warm footbaths found mixed evidence regarding benefits and thus could not draw conclusions about the effects of these nonpharmacological interventions in reducing cancer pain.V (Im, In)
      Nonpharmacological physical (oxygen, cool air, ventilation)

      Adults and mixed samples

      Outcome: dyspnea management
      2 SRs
      • Wilson M.E.
      • Majzoub A.M.
      • Dobler C.C.
      • et al.
      Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: a systematic review and meta-analysis.
      • Bausewein C.
      • Simon S.T.
      • Pralong A.
      • et al.
      Palliative care of adult patients with cancer.
      Two reviews reported dyspnea management outcomes related to nonpharmacological physical interventions. One review reported moderate efficacy of a stream of cool air on the face in reducing breathlessness and also reported high-quality evidence that oxygen is not effective for relief of breathlessness in nonhypoxemic patients (SMD −0.09; CI −0.22, 0.04).
      • Bausewein C.
      • Simon S.T.
      • Pralong A.
      • et al.
      Palliative care of adult patients with cancer.
      Another review found only a single RCT showing that noninvasive ventilation was associated with mild improvements in dyspnea, but this was only significant for a subgroup of patients with hypercapnia.
      L (In)
      Nonpharmacological physical (oxygen, cool air, yoga)

      Adults and mixed samples

      Outcome: function
      1 SR
      • Deng G.E.
      • Rausch S.M.
      • Jones L.W.
      • et al.
      Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines.
      One review identified a single RCT demonstrating that yoga significantly improved physical functioning, and two RCTs demonstrating that taichi significantly improved functional capacity among adult cancer patients.L (Im)
      Psychosocial

      Adults and mixed samples

      Outcome: physical function
      1 SR
      • Poort H.
      • Peters M.
      • Bleijenberg G.
      • et al.
      Psychosocial interventions for fatigue during cancer treatment with palliative intent.
      One review concluded that very low-quality evidence indicates that psychological therapies may improve physical functioning directly after the intervention (SMD 0.32; CI 0.01, 0.63, seven RCTs), and at first follow-up, psychosocial interventions were not associated with statistically significant improvement in physical functioning (SMD 0.37, CI −0.20, 0.94; two RCTs).
      • Poort H.
      • Peters M.
      • Bleijenberg G.
      • et al.
      Psychosocial interventions for fatigue during cancer treatment with palliative intent.
      V (S, In)
      Nonpharmacological cognitive (relaxation, imagery)

      Adults and mixed samples

      Outcome: pain management
      1 SR
      • Hokka M.
      • Kaakinen P.
      • Polkki T.
      A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer.
      One review examining cognitive modalities such as relaxation, distraction, and imagery exercises found mixed evidence regarding benefits and thus could not draw conclusions about the effects and safety of the nonpharmacological interventions in reducing cancer pain.V (Im, In)
      Nonpharmacological cognitive (relaxation, imagery, hypnosis)

      Adults and mixed samples

      Outcome: dyspnea management
      1 SR
      • Latorraca C.O.C.
      • Martimbianco A.L.C.
      • Pachito D.V.
      • Pacheco R.L.
      • Riera R.
      Mindfulness for palliative care patients. Systematic review.
      One review concluded that mindfulness meditation schemes did not show a statistically significant benefit at improving dyspnea management, based on a single RCT.V (Im, In)
      Information and communication tools (telehealth, web sites)

      Adults and mixed samples

      Outcome: pain
      1 SR
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      One review found two RCTs and one time-series study demonstrating improvements in pain and symptom control associated with telephone, Web-based, and video tools, but studies used various measures and the review did not report effect estimates.L (Im)
      Organizational quality improvement

      Adults and mixed samples

      Outcome: symptom improvement
      1 SR
      • Lau B.D.
      • Aslakson R.A.
      • Wilson R.F.
      • et al.
      Methods for improving the quality of palliative care delivery: a systematic review.
      One review examining various quality improvement interventions and outcomes found five RCTs; three RCTs reported nonsignificant improvements in symptoms with patient education and self-management; two RCTs reported significant improvements in symptoms.V (Im, In)
      N = number of systematic reviews; RT = radiotherapy; SR = systematic review; RCT(s) = randomized controlled trial(s); L = low quality of evidence; Im = imprecision; In = inconsistency; SMD = standardized mean difference; M = moderate quality of evidence; S = study limitation; MD = mean difference; V = very low quality of evidence; OR = odds ratio.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 3Psychological and Psychiatric Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Pediatric interventions0NANA
      Comprehensive palliative care

      Adults and mixed samples

      Outcome: mood
      1 SR
      • Kavalieratos D.
      • Corbelli J.
      • Zhang D.
      • et al.
      Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis.
      One review concluded there is mixed evidence from 23 trials of associations of palliative care with improved patient mood.L (Im, In)
      Social support

      Adults

      Outcome: mood
      1 SR
      • Bradley N.
      • Lloyd-Williams M.
      • Dowrick C.
      Effectiveness of palliative care interventions offering social support to people with life-limiting illness-A systematic review.
      One review concluded that social support interventions may have a positive impact on mood disturbance but noted that outcome measures and study designs were heterogenous.L (S, Im)
      Psychosocial interventions

      Adults

      Outcome: depression
      2 SRs
      • Cagle J.G.
      • Bunting M.
      • Kelemen A.
      • et al.
      Psychosocial needs and interventions for heart failure patients and families receiving palliative care support: a systematic review.
      • Okuyama T.
      • Akechi T.
      • Mackenzie L.
      • Furukawa T.A.
      Psychotherapy for depression among advanced, incurable cancer patients: a systematic review and meta-analysis.
      Two reviews reported depression outcomes related to psychosocial and psychotherapeutic interventions. One review found that psychotherapy was associated with moderate decrease in depression score (SMD −0.67; CI −1.06, −0.29; 12 studies).
      • Okuyama T.
      • Akechi T.
      • Mackenzie L.
      • Furukawa T.A.
      Psychotherapy for depression among advanced, incurable cancer patients: a systematic review and meta-analysis.
      Another review identified a single RCT demonstrating no significant impact of a psycho-educational intervention on patient depression but also found a prospective study reporting improvements in depression after palliative care consultation with a psychosocial component.
      L (In)
      Psychosocial interventions

      Adults

      Outcome: quality of life
      1 SR
      • Cagle J.G.
      • Bunting M.
      • Kelemen A.
      • et al.
      Psychosocial needs and interventions for heart failure patients and families receiving palliative care support: a systematic review.
      One review found one RCT and one prospective study demonstrating that a palliative care consultation with a psychosocial component improves quality of life.L (Im)
      Psycho/spiritual (life review, dignity therapy)

      Adults

      Outcome: depression
      5 SRs
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      • Martinez M.
      • Arantzamendi M.
      • Belar A.
      • et al.
      Dignity therapy', a promising intervention in palliative care: a comprehensive systematic literature review.
      • Fitchett G.
      • Emanuel L.
      • Handzo G.
      • Boyken L.
      • Wilkie D.J.
      Care of the human spirit and the role of dignity therapy: a systematic review of dignity therapy research.
      • Piderman K.M.
      • Kung S.
      • Jenkins S.M.
      • et al.
      Respecting the spiritual side of advanced cancer care: a systematic review.
      • Chen Y.
      • Xiao H.
      • Yang Y.
      • Lan X.
      The effects of life review on psycho-spiritual well-being among patients with life-threatening illness: a systematic review and meta-analysis.
      Five systematic reviews reported depression outcomes related to psychospiritual interventions and found mixed evidence. One review reported evidence that life review interventions can improve depressive symptoms (SMD −0.78; CI −1.46, −0.11; five RCTs) but noted considerable heterogeneity across studies.
      • Chen Y.
      • Xiao H.
      • Yang Y.
      • Lan X.
      The effects of life review on psycho-spiritual well-being among patients with life-threatening illness: a systematic review and meta-analysis.
      One review found mixed evidence on the effects of dignity therapy on depression and concluded that effects of dignity therapy on depression are still controversial, requiring further evidence on greater impact. Similarly, another review also concluded that additional research is needed to determine the efficacy of dignity therapy. One review identified a single nonrandomized study reporting decreases in depression after a manualized psychospiritual therapy intervention. One review found a single RCT of dignity therapy among patients with high levels of psychological distress and demonstrated significant improvements in depression scores; however, another RCT demonstrated no significant improvement in depression related to dignity therapy.
      V (S, In)
      Psycho/spiritual (life review, dignity therapy)

      Adults

      Outcome: anxiety
      7 SRs
      • Grossman C.H.
      • Brooker J.
      • Michael N.
      • Kissane D.
      Death anxiety interventions in patients with advanced cancer: a systematic review.
      • Wang C.W.
      • Chow A.Y.
      • Chan C.L.
      The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: a systematic review and meta-analysis of randomized controlled trials.
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      • Martinez M.
      • Arantzamendi M.
      • Belar A.
      • et al.
      Dignity therapy', a promising intervention in palliative care: a comprehensive systematic literature review.
      • Fitchett G.
      • Emanuel L.
      • Handzo G.
      • Boyken L.
      • Wilkie D.J.
      Care of the human spirit and the role of dignity therapy: a systematic review of dignity therapy research.
      • Piderman K.M.
      • Kung S.
      • Jenkins S.M.
      • et al.
      Respecting the spiritual side of advanced cancer care: a systematic review.
      • Chen Y.
      • Xiao H.
      • Yang Y.
      • Lan X.
      The effects of life review on psycho-spiritual well-being among patients with life-threatening illness: a systematic review and meta-analysis.
      Seven reviews reported anxiety outcomes related to psychospiritual interventions and found mixed evidence. Two reviews reported evidence that life review interventions can improve anxiety among patients with life-threatening illnesses. One review found mixed evidence on the effects of dignity therapy on anxiety and concluded that effects of dignity therapy on anxiety are still controversial, requiring further evidence on greater impact. Similarly, another review also concluded that additional research is needed to determine the efficacy of dignity therapy for anxiety. One review of various psychospiritual interventions reported that meaning-centered couples therapy, dignity therapy, and a brief psychotherapy intervention to relieve distress were all associated with decreased death anxiety. One review identified a single study reporting decreases in anxiety after a manualized psychospiritual therapy intervention. One review found a single RCT of dignity therapy among patients with high levels of psychological distress and demonstrated significant improvements in anxiety scores; however, another RCT demonstrated no significant improvement in anxiety related to dignity therapy.V (Im, In)
      Psychospiritual (life review, dignity)

      Adults

      Outcome: distress
      1 SR
      • Wang C.W.
      • Chow A.Y.
      • Chan C.L.
      The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: a systematic review and meta-analysis of randomized controlled trials.
      One review concluded that life review interventions may be effective in alleviating general distress (SMD −0.32; CI −0.55, −0.09; five RCTs) but no significant results were reported for psychological distress.
      • Wang C.W.
      • Chow A.Y.
      • Chan C.L.
      The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: a systematic review and meta-analysis of randomized controlled trials.
      L (In)
      Pharmacological interventions

      Adults

      Outcome: depression
      3 SRs
      • Berger A.M.
      • Yennu S.
      • Million R.
      Update on interventions focused on symptom clusters: what has been tried and what have we learned?.
      • Reiche S.
      • Hermle L.
      • Gutwinski S.
      • et al.
      Serotonergic hallucinogens in the treatment of anxiety and depression in patients suffering from a life-threatening disease: a systematic review.
      Three reviews reported depression outcomes related to pharmacological interventions; none reported effect estimates. One review found a single RCT demonstrating that methylphenidate reduced symptoms of depression compared to placebo. One review found limited evidence from uncontrolled cohort studies in favor of methylphenidate, oxcarbazepine, bupropion SR, ginkgo biloba, and donepezil compared with placebo for treatment of depression in adult patients with glioma and concluded that it remains unknown whether any of these treatments are effective for depressive disorder. A third review concluded on the basis of four recent clinical trials that the use of serotonergic hallucinogens may improve depressive symptoms among patients with life-threatening illness.V (S, Im)
      Cannabinoids

      Adults

      Outcome: depression
      1 SR
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      One review found two RCTs reporting no significant differences between cannabinoids and placebo in the treatment of depression.M (Im)
      Cannabinoids

      Adults

      Outcome: well-being (negative effect)
      1 SR
      • Mucke M.
      • Weier M.
      • Carter C.
      • et al.
      Systematic review and meta-analysis of cannabinoids in palliative medicine.
      One review reported very low quality of evidence suggesting the effect of cannabinoids for reduction of negative effect compared with placebo, on the basis of a single RCT.V (Im, In)
      Nonpharmacological cognitive (meditation, relaxation, imagery, hypnosis)

      Adults and mixed samples

      Outcome: depression
      2 SRs
      • Pace A.
      • Dirven L.
      • Koekkoek J.A.F.
      • et al.
      European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma.
      • Zimmermann F.F.
      • Burrell B.
      • Jordan J.
      The acceptability and potential benefits of mindfulness-based interventions in improving psychological well-being for adults with advanced cancer: a systematic review.
      Two reviews reported depression outcomes but neither review reported effect estimates. One review identified a single RCT of a multimodal psychosocial intervention demonstrating clinically significant benefit on depressive symptoms. Another review found a large and medium of mindfulness-based interventions on depression.L (Im, In)
      Nonpharmacological cognitive (meditation, relaxation, imagery, hypnosis)

      Adults and mixed samples

      Outcome: quality of life
      3 SRs
      • Latorraca C.O.C.
      • Martimbianco A.L.C.
      • Pachito D.V.
      • Pacheco R.L.
      • Riera R.
      Mindfulness for palliative care patients. Systematic review.
      • Deng G.E.
      • Rausch S.M.
      • Jones L.W.
      • et al.
      Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines.
      • Zimmermann F.F.
      • Burrell B.
      • Jordan J.
      The acceptability and potential benefits of mindfulness-based interventions in improving psychological well-being for adults with advanced cancer: a systematic review.
      Three reviews reported mixed evidence regarding quality of life outcomes but none reported effect estimates. One review found a single RCT reporting no significant differences between mindfulness meditation and controls in quality of life–physical and mental aspects for adult cancer patients. Another review found a large and medium effect of mindfulness-based interventions on cancer-specific quality of life. One review found a single RCT demonstrating improvements in quality of life associated with transcendental meditation.L (Im, In)
      Non-pharmacological cognitive (meditation, relaxation, imagery, hypnosis)

      Adults and mixed samples

      Outcome: well-being (stress)
      3 SRs
      • Latorraca C.O.C.
      • Martimbianco A.L.C.
      • Pachito D.V.
      • Pacheco R.L.
      • Riera R.
      Mindfulness for palliative care patients. Systematic review.
      • Deng G.E.
      • Rausch S.M.
      • Jones L.W.
      • et al.
      Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines.
      • Zimmermann F.F.
      • Burrell B.
      • Jordan J.
      The acceptability and potential benefits of mindfulness-based interventions in improving psychological well-being for adults with advanced cancer: a systematic review.
      Three reviews reported mixed evidence regarding quality of life outcomes but none reported effect estimates. One review found a single RCT reported low-level evidence suggesting mindfulness meditation improves perceived stress for adult cancer patients. Another review found a medium effect of mindfulness-based interventions on reducing negative emotions, increasing general well-being and relaxation and overall mood. One review found a single RCT demonstrating improvements in emotional well-being associated with transcendental meditation.L (Im, In)
      Nonpharmacological physical (acupuncture, massage, noninvasive ventilation, yoga)

      Adults and mixed samples

      Outcome: anxiety
      4 SRs
      • Wilson M.E.
      • Majzoub A.M.
      • Dobler C.C.
      • et al.
      Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: a systematic review and meta-analysis.
      • Pace A.
      • Dirven L.
      • Koekkoek J.A.F.
      • et al.
      European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma.
      • Deng G.E.
      • Rausch S.M.
      • Jones L.W.
      • et al.
      Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines.
      • Berger A.M.
      • Yennu S.
      • Million R.
      Update on interventions focused on symptom clusters: what has been tried and what have we learned?.
      Four reviews reported mixed evidence anxiety outcomes of nonpharmacological physical interventions but none reported effect estimates. One review identified a single RCT reporting that acupuncture had transient effects on anxiety. One review concluded that there is limited evidence suggesting a possible beneficial role of massage therapy for anxiety. Another review found no significant association between noninvasive ventilation and improvements in anxiety. Another review studying yoga found a single RCT reporting significant improvements in anxiety.V (S, Im, In)
      Nonpharmacological physical (acupuncture, noninvasive ventilation, yoga)

      Adults and mixed samples

      Outcome: depression
      3 SR
      • Wilson M.E.
      • Majzoub A.M.
      • Dobler C.C.
      • et al.
      Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: a systematic review and meta-analysis.
      • Deng G.E.
      • Rausch S.M.
      • Jones L.W.
      • et al.
      Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines.
      • Berger A.M.
      • Yennu S.
      • Million R.
      Update on interventions focused on symptom clusters: what has been tried and what have we learned?.
      Three reviews reported depression outcomes of nonpharmacological physical interventions but none reported effect estimates. One review identified a single RCT reporting that acupuncture had transient effects on depression. One review reported no significant association between noninvasive ventilation and improvements in depression.V (S, Im, In)
      Nonpharmacological nurse-led interventions (telemonitoring, education, complementary care)

      Adults and mixed samples

      Outcome: anxiety
      1 SR
      • Zweers D.
      • de Graaf E.
      • Teunissen S.C.
      Non-pharmacological nurse-led interventions to manage anxiety in patients with advanced cancer: a systematic literature review.
      One review found seven RCTs examining the role of nurses in addressing anxiety in patients with advanced cancer; two demonstrated significant improvements in anxiety associated with a psychoeducational intervention and a telemonitoring program. However, another RCT of a telemonitoring program and an RCT of a complementary care program found no significant changes in anxiety associated with the interventions.V (S, Im, In)
      Music/art therapy

      Adults

      Outcome: anxiety
      3 SRs
      • Schmid W.
      • Rosland J.H.
      • von Hofacker S.
      • Hunskar I.
      • Bruvik F.
      Patient's and health care provider's perspectives on music therapy in palliative care - an integrative review.
      • McConnell T.
      • Scott D.
      • Porter S.
      Music therapy for end-of-life care: an updated systematic review.
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Three reviews reported anxiety outcomes for music/art therapies. One review reported that creative art therapies significantly reduced anxiety compared to controls (SMD 0.28; CI 0.11–0.44; 25 RCTs) after intervention.
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Another review found four studies (one RCT and three pre-post) demonstrating positive effects of music therapy on anxiety. Finally, a third review found two studies examining the effect of music therapy; both found significant reductions in anxiety associated with the intervention.
      M (Im)
      Music/art therapy

      Adults

      Outcome: depression
      2 SRs
      • Schmid W.
      • Rosland J.H.
      • von Hofacker S.
      • Hunskar I.
      • Bruvik F.
      Patient's and health care provider's perspectives on music therapy in palliative care - an integrative review.
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Two reviews reported depression outcomes for music/art therapies and the effects were positive. One review reported that creative arts therapies significantly reduced depression compared to no treatment, waiting list, usual care, or placebo controls (SMD 0.23; CI 0.05, 0.40; 11 RCTs) after intervention.
      • Puetz T.W.
      • Morley C.A.
      • Herring M.P.
      Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.
      Another review found three studies (one RCT and two pre-post) demonstrating mixed effects of music therapy on depression.
      M (In)
      Information and communication tools (telehealth, web sites)

      Adults and mixed samples

      Outcome: emotional well-being
      1 SR
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      One review found one pre-post study showing videoconferencing significantly improved anxiety for patients at rural health care sites, and one RCT showing that palliative care telephone support significantly improved mood and emotional bother but did not report effect estimates.L (Im)
      Education

      Adults

      Outcome: depression
      1 SR
      • Nevis I.
      Educational intervention in end-of-life care: an evidence-based analysis.
      One review identified a single RCT of an educational intervention for health care professionals that reported a significant improvement in depressive symptoms among patients nearing the end of life.V (Im, In)
      Exercise

      Adults

      Outcome: anxiety
      1 SR
      • Dittus K.L.
      • Gramling R.E.
      • Ades P.A.
      Exercise interventions for individuals with advanced cancer: a systematic review.
      One review found a single pre-post single-arm study demonstrating positive effect of exercise on anxiety.V (S, Im, In)
      Exercise

      Adults

      Outcome: depression
      1 SR
      • Dittus K.L.
      • Gramling R.E.
      • Ades P.A.
      Exercise interventions for individuals with advanced cancer: a systematic review.
      One review concluded that based on two pre-post single-arm studies and one program evaluation study, exercise does not improve depression.V (S, Im)
      N = number of systematic reviews; NA = not applicable; SR = systematic review; L = low quality of evidence; Im = imprecision; In = inconsistency; S = study limitation; SMD = standardized mean difference; RCT(s) = randomized controlled trial(s); V = very low quality of evidence; M = moderate quality of evidence.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 4Social Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Pediatrics0NANA
      Social work interventions

      Adults

      Outcome: identification of and access to social services
      1 SR
      • Alcide A.
      • Potocky M.
      Adult hospice social work intervention outcomes in the United States.
      One review found that various caregiver support services helped to identify caregivers' direct support service needs, decreased caregiver role overload, and led to a nonsignificant increase in social support and benefits finding; however, the review reported no effect estimate across studies.L (Im)
      Social support

      Adults

      Outcome: social support
      1 SR
      • Bradley N.
      • Lloyd-Williams M.
      • Dowrick C.
      Effectiveness of palliative care interventions offering social support to people with life-limiting illness-A systematic review.
      One review reported findings from a single RCT of group therapy for patients with life-limiting illness that showed no demonstrable difference in social support; the review did not report effect estimates.V (Im, In)
      N = number of systematic reviews; NA = not applicable; SR = systematic review; L = low quality of evidence; Im = imprecision; RCT(s) = randomized controlled trial(s); V = very low quality of evidence; In = inconsistency.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 5Spiritual, Religious, and Existential Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Pediatric spiritual interventions0NANA
      Spiritual interventions

      Family/caregiver outcome
      0NANA
      Spiritual/religious interventions

      Adults and mixed samples

      Patient outcome: spiritual well-being
      3 SRs
      • Piderman K.M.
      • Kung S.
      • Jenkins S.M.
      • et al.
      Respecting the spiritual side of advanced cancer care: a systematic review.
      • Candy B.
      • Jones L.
      • Varagunam M.
      • et al.
      Spiritual and religious interventions for well-being of adults in the terminal phase of disease.
      • Catania G.
      • Bagnasco A.
      • Zanini M.
      • Aleo G.
      • Sasso L.
      Spiritual assessment within clinical interventions focused on quality of life assessment in palliative care: a secondary analysis of a systematic review.
      Three reviews reported mixed evidence regarding spiritual well-being outcomes but none reported effect estimates. One review reported inconclusive evidence that interventions with spiritual or religious components for adults in the terminal phase of a disease may or may not enhance well-being. Similarly, a second review found only nonsignificant improvements in spiritual well-being associated with different spiritual interventions. However, one review found three studies of spiritual interventions with demonstrated improvements in spiritual well-being.V (Im, In)
      Life review/dignity therapy

      Adults and mixed samples

      Patient outcome: spiritual well-being
      5 SRs
      • Grossman C.H.
      • Brooker J.
      • Michael N.
      • Kissane D.
      Death anxiety interventions in patients with advanced cancer: a systematic review.
      • Wang C.W.
      • Chow A.Y.
      • Chan C.L.
      The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: a systematic review and meta-analysis of randomized controlled trials.
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      • Fitchett G.
      • Emanuel L.
      • Handzo G.
      • Boyken L.
      • Wilkie D.J.
      Care of the human spirit and the role of dignity therapy: a systematic review of dignity therapy research.
      • Keall R.M.
      • Clayton J.M.
      • Butow P.N.
      Therapeutic life review in palliative care: a systematic review of quantitative evaluations.
      Five reviews reported spiritual well-being outcomes of life review/dignity therapy interventions and found mixed evidence. A 2017 review reported beneficial effects of life review on spiritual well-being (SMD 0.33; CI 0.12, 0.53; four RCTs)
      • Wang C.W.
      • Chow A.Y.
      • Chan C.L.
      The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: a systematic review and meta-analysis of randomized controlled trials.
      but noted a high degree of heterogeneity. Another review also found that life review was associated with improvements in spiritual well-being. One review described evidence that dignity therapy was associated with decreased existential distress, enhanced interpersonal and transpersonal spirituality, and improved spiritual well-being. Another review also found that dignity therapy was associated with higher levels of spiritual well-being. A fifth review found that life review was associated with improved spiritual well-being and existential distress but that dignity therapy was not associated with significant improvement in existential domains.
      M (In)
      Life review/dignity therapy

      Adults and mixed samples

      Patient outcome: meaning and purpose
      3 SRs
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      • Fitchett G.
      • Emanuel L.
      • Handzo G.
      • Boyken L.
      • Wilkie D.J.
      Care of the human spirit and the role of dignity therapy: a systematic review of dignity therapy research.
      • Chen Y.
      • Xiao H.
      • Yang Y.
      • Lan X.
      The effects of life review on psycho-spiritual well-being among patients with life-threatening illness: a systematic review and meta-analysis.
      In one review of life review interventions, two RCTs found no significant differences in purpose in life between life review and control groups. Owing to reported heterogeneity, pooled estimates were not calculated. One review reported that moderate to high level of evidence shows that dignity therapy increases sense of purpose and another review of dignity therapy interventions found two RCTs where the intervention was associated with higher levels of meaning in life.L (Im, In)
      Life review/dignity therapy

      Adults and mixed samples

      Patient outcome: will to live
      1 SR
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      Dignity therapy was associated with increased will to live in a single RCT described in the review.L (Im, In)
      Life review/dignity therapy

      Adults and mixed samples

      Patient outcome: acceptance of death
      1 SR
      • Donato S.C.
      • Matuoka J.Y.
      • Yamashita C.C.
      • Salvetti M.G.
      Effects of dignity therapy on terminally ill patients: a systematic review.
      The review identified one quasi-experimental study reporting acceptance of death one month after dignity therapy.V (S, Im, In)
      Life review/dignity therapy

      Adults and mixed samples

      Patient outcome: emotional well-being
      1 SR
      • Martinez M.
      • Arantzamendi M.
      • Belar A.
      • et al.
      Dignity therapy', a promising intervention in palliative care: a comprehensive systematic literature review.
      One review found a single RCT of dignity therapy among patients with high levels of psychological distress and demonstrated significant improvements in anxiety and depression scores. However, another RCT demonstrated no significant improvement in anxiety or depression related to dignity therapy.L (Im, In)
      Meaning-centered interventions

      Adults and mixed samples

      Patient outcome: spiritual well-being
      3 SRs
      • Grossman C.H.
      • Brooker J.
      • Michael N.
      • Kissane D.
      Death anxiety interventions in patients with advanced cancer: a systematic review.
      • Guerrero-Torrelles M.
      • Monforte-Royo C.
      • Rodriguez-Prat A.
      • Porta-Sales J.
      • Balaguer A.
      Understanding meaning in life interventions in patients with advanced disease: a systematic review and realist synthesis.
      • Keall R.M.
      • Clayton J.M.
      • Butow P.N.
      Therapeutic life review in palliative care: a systematic review of quantitative evaluations.
      In three reviews, meaning in life interventions was associated with improvements in spiritual well-being but effect estimates were not reported and effects varied by study and outcome.L (Im, In)
      Meaning-centered interventions

      Adults and mixed samples

      Patient outcome: emotional well-being
      1 SR
      • Guerrero-Torrelles M.
      • Monforte-Royo C.
      • Rodriguez-Prat A.
      • Porta-Sales J.
      • Balaguer A.
      Understanding meaning in life interventions in patients with advanced disease: a systematic review and realist synthesis.
      In one review, meaning in life interventions was associated with clinical benefits on measures of hopelessness, anxiety, and depression but effect estimates were not reported and effects varied by study and outcome.V (Im, In)
      Meaning-centered interventions

      Adults and mixed samples

      Patient outcome: meaning and purpose
      1 SR
      • Guerrero-Torrelles M.
      • Monforte-Royo C.
      • Rodriguez-Prat A.
      • Porta-Sales J.
      • Balaguer A.
      Understanding meaning in life interventions in patients with advanced disease: a systematic review and realist synthesis.
      In one review, meaning in life interventions were associated with clinical benefits on measures of purpose in life but effect estimates were not reported and effects varied by study and outcome.V (Im, In)
      Meaning-centered interventions

      Adults and mixed samples

      Patient outcome: quality of life
      1 SR
      • Guerrero-Torrelles M.
      • Monforte-Royo C.
      • Rodriguez-Prat A.
      • Porta-Sales J.
      • Balaguer A.
      Understanding meaning in life interventions in patients with advanced disease: a systematic review and realist synthesis.
      In one review, meaning in life interventions were associated with clinical benefits on measures of quality of life but effect estimates were not reported and effects varied by study and outcome.V (Im, In)
      Meaning-centered interventions

      Adults and mixed samples

      Patient outcome: will to live
      1 SR
      • Guerrero-Torrelles M.
      • Monforte-Royo C.
      • Rodriguez-Prat A.
      • Porta-Sales J.
      • Balaguer A.
      Understanding meaning in life interventions in patients with advanced disease: a systematic review and realist synthesis.
      In one review, meaning in life interventions was associated with clinical benefits on measures of wish to hasten death but effect estimates were not reported and effects varied by study and outcome.V (Im, In)
      N = number of systematic reviews; NA = not applicable; SR = systematic review; V = very low quality of evidence; Im = imprecision; In = inconsistency; SMD = standardized mean difference; M = moderate quality of evidence; RCT(s) = randomized controlled trial(s); L = low quality of evidence; S = study limitation.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 6Cultural Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Pediatric interventions0NANA
      Culturally relevant palliative care

      Adults and mixed samples

      Patient outcome: DNR
      1 SR
      • Isaacson M.J.
      • Lynch A.R.
      Culturally relevant palliative and end-of-life care for U.S. Indigenous populations: an integrative review.
      One review found one study of a culturally tailored inpatient palliative care consultation services reporting a postintervention increase in DNR completion among Native American patients but did not report effect estimates.V (S, Im, In)
      Culturally relevant palliative care

      Adults and mixed samples

      Patient outcome: quality of death/dying
      1 SR
      • Applebaum A.J.
      • Breitbart W.
      Care for the cancer caregiver: a systematic review.
      One review found a single pilot study reporting significant increases in coping skills and significant decreases in depressive symptoms among patients but did not report effect estimates.V (S, Im, In)
      Culturally relevant palliative care

      Adults and mixed samples

      Family/caregiver outcome: quality of death/dying
      1 SR
      • Applebaum A.J.
      • Breitbart W.
      Care for the cancer caregiver: a systematic review.
      One review found a single pilot study reporting significant increases in coping skills and in self-efficacy among caregivers but did not report effect estimates.V (S, Im, In)
      Interpreters

      Adults and mixed samples

      Patient outcome: quality of care
      1 SR
      • Silva M.D.
      • Genoff M.
      • Zaballa A.
      • et al.
      Interpreting at the end of life: a systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.
      One review concluded that improving access to and/or standardizing utilization of professional interpreter services could improve the quality of care provided to patients at the end of life but did not report effect estimates.V (S, Im, In)
      Interpreters

      Adults and mixed samples

      Patient outcome: communication
      1 SR
      • Silva M.D.
      • Genoff M.
      • Zaballa A.
      • et al.
      Interpreting at the end of life: a systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.
      One review found a single pilot study reporting significant increases in coping skills and in self-efficacy among caregivers but did not report effect estimates.V (S, Im, In)
      Interpreters

      Adults and mixed samples

      Family/caregiver outcome: information sharing
      1 SR
      • Silva M.D.
      • Genoff M.
      • Zaballa A.
      • et al.
      Interpreting at the end of life: a systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.
      One review concluded that improving access to and/or standardizing utilization of professional interpreter services could improve the quality of care provided to patients at the end of life but did not report effect estimates.V (S, Im, In)
      N = number of systematic reviews; NA = not applicable; SR = systematic review; DNR = do-not-resuscitate; V = very low quality of evidence; S = study limitation; Im = imprecision; In = inconsistency.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 7Care of the Patient Nearing the End of Life
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Grief/bereavement support services

      Pediatric

      Child outcome: grief
      2 SRs
      • Donovan L.A.
      • Wakefield C.E.
      • Russell V.
      • Cohn R.J.
      Hospital-based bereavement services following the death of a child: a mixed study review.
      • Bergman A.-S.
      • Axberg U.
      • Hanson E.
      When a parent dies–a systematic review of the effects of support programs for parentally bereaved children and their caregivers.
      Two reviews reported pediatric grief outcomes and found positive effects. One review identified five studies with strong evidence on medium to large effects of grief and bereavement support on parentally bereaved children's traumatic grief symptoms. Another review found some evidence that bereavement services for bereaved child siblings contributed positively to the grief experience. Neither review reported effect estimates across studies.M (Im)
      Grief/bereavement support services

      Pediatric

      Child outcome: emotional well-being
      2 SRs
      • Donovan L.A.
      • Wakefield C.E.
      • Russell V.
      • Cohn R.J.
      Hospital-based bereavement services following the death of a child: a mixed study review.
      • Bergman A.-S.
      • Axberg U.
      • Hanson E.
      When a parent dies–a systematic review of the effects of support programs for parentally bereaved children and their caregivers.
      Two reviews reported pediatric emotional well-being outcomes and found mixed evidence. One review identified some studies with strong evidence on small effects for parentally bereaved children's PTSD symptoms (one study), anxiety (two studies), and depression in girls (one study); one study identified in the same review did not show effects for boys on the anxiety and depression. Another review identified one study demonstrating a positive effect of group-based grief/bereavement services on bereaved child siblings' sense of isolation, development of healing friendships, and coping skills. Neither review reported effect estimates across studies.L (Im, In)
      Grief/bereavement support services

      Pediatric

      Adult family outcome: grief
      2 SRs
      • Donovan L.A.
      • Wakefield C.E.
      • Russell V.
      • Cohn R.J.
      Hospital-based bereavement services following the death of a child: a mixed study review.
      • Bergman A.-S.
      • Axberg U.
      • Hanson E.
      When a parent dies–a systematic review of the effects of support programs for parentally bereaved children and their caregivers.
      Two reviews reported bereaved parent grief outcomes and found mixed evidence. One review identified two studies with strong evidence on medium effects for grief discussions in the family; another study with strong evidence identified in the same review showed no effects of grief/bereavement services on bereaved parents' present grief. Another review found mixed evidence on the positive impact of grief/bereavement services for bereaved parents and concluded that bereavement services are most effective for parents experiencing more complex mourning. Neither review reported effect estimates.L (Im, In)
      Grief/bereavement support services

      Pediatric

      Adult family outcome: emotional well-being
      2 SRs
      • Donovan L.A.
      • Wakefield C.E.
      • Russell V.
      • Cohn R.J.
      Hospital-based bereavement services following the death of a child: a mixed study review.
      • Bergman A.-S.
      • Axberg U.
      • Hanson E.
      When a parent dies–a systematic review of the effects of support programs for parentally bereaved children and their caregivers.
      Two reviews reported emotional well-being outcomes related to parental grief/bereavement support interventions and found conflicting evidence. One review found evidence on the impact of grief/bereavement services on bereaved parents' feelings of being supported; parental depression; and mental health. However, two studies identified in the same review with strong evidence showed no effects on depression. Another review found qualitative evidence on improvements in bereaved parents' emotional status after a group-based grief/bereavement support group. Neither review reported effect estimates.L (Im, In)
      Grief/bereavement support services

      Adults

      Adult family outcome: grief
      1 SR
      • Arruda E.H.
      • Paun O.
      Dementia caregiver grief and bereavement: an integrative review.
      One review found that bereaved caregivers participating in predeath grief interventions had more favorable postdeath emotional health outcomes, including lower levels of grief, but did not report effect estimates.L (Im)
      Grief/bereavement support services

      Adults

      Adult family outcome: emotional well-being
      2 SRs
      • Applebaum A.J.
      • Breitbart W.
      Care for the cancer caregiver: a systematic review.
      • Arruda E.H.
      • Paun O.
      Dementia caregiver grief and bereavement: an integrative review.
      Two reviews reported family emotional well-being outcomes and found positive effects but neither reported effect estimates. One review identified a single RCT of family group therapy that demonstrated reductions in distress and depressive symptoms among informal caregivers for cancer patients. Another review found evidence showing that receiving affective support both before and after family members' death mediates negative bereavement outcomes such as depressive symptoms, anxiety, and guilt in bereaved caregivers.L (Im)
      Grief counseling/therapy

      Adults

      Adult family outcome: grief
      2 SRs
      • Wilson S.
      • Toye C.
      • Aoun S.
      • et al.
      Effectiveness of psychosocial interventions in reducing grief experienced by family carers of people with dementia: a systematic review.
      • Waller A.
      • Turon H.
      • Mansfield E.
      • et al.
      Assisting the bereaved: a systematic review of the evidence for grief counselling.
      Two reviews reported grief outcomes related to grief counseling/therapy interventions and found mixed evidence on impact but neither reported effect estimates. In one review, complicated grief therapy was found to be more effective than interpersonal psychotherapy in reducing abnormal grief. Another review found that grief management and counseling interventions did not have a significant impact on caregiver anticipatory grief but did find a single RCT demonstrating small improvements in postdeath and complicated grief outcomes after a multicomponent grief counseling intervention.V (S, Im, In)
      Grief counseling/therapy

      Adults

      Adult family outcome: emotional well-being
      1 SR
      • Waller A.
      • Turon H.
      • Mansfield E.
      • et al.
      Assisting the bereaved: a systematic review of the evidence for grief counselling.
      In one review, complicated grief therapy was found to be more effective than interpersonal psychotherapy in improving work and social adjustment; however, the review did not report effect estimates.V (S, Im)
      End-of-life care

      Pediatric
      0NANA
      End-of-life care—pharmacological sedation

      Adults

      Outcome: quality of care
      1 SR
      • Beller E.M.
      • van Driel M.L.
      • McGregor L.
      • Truong S.
      • Mitchell G.
      Palliative pharmacological sedation for terminally ill adults.
      One review found four nonrandomized studies comparing sedated and nonsedated groups and showed that despite sedation with the intent to control symptoms, delirium and dyspnea were still troublesome symptoms in these people in the last few days of life and were significantly worse in the sedated group. Control of other symptoms appeared to be similar in sedated and nonsedated groups. In addition, all studies identified in the review except one compared survival time in the sedated and nonsedated groups and concluded that there was no statistically significant difference between the groups. The review did not report effect estimates.V (S, Im)
      End-of-life care—pharmacological symptom control

      Adults

      Outcome: quality of care
      1 SR
      • Jansen K.
      • Haugen D.F.
      • Pont L.
      • Ruths S.
      Safety and effectiveness of palliative drug treatment in the last days of life-A systematic literature review.
      One review examining a range of palliative interventions and outcomes concluded that there is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients. No evidence was found for scopolamine hydrobromide and atropine for death rattle; some evidence was found supporting the use of morphine and midazolam for dyspnea, anxiety, or terminal restlessness; and some support was found for morphine, diamorphine, and fentanyl for pain. The review did not report effect estimates.V (Im, In)
      N = number of systematic reviews; SR = systematic review; M = moderate quality of evidence; Im = imprecision; PTSD = post-traumatic stress disorder; L = low quality of evidence; In = inconsistency; RCT(s) = randomized controlled trial(s); V = very low quality of evidence; S = study limitation; NA = not applicable.
      a The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Summary of Findings Table 8Ethical and Legal Aspects of Care
      Intervention and Comparator

      Age Group

      Setting

      Outcome
      NEffect Estimate and Direction of EffectsGRADE
      The GRADE category is based on identified systematic reviews published between 2013 and February 2018. We used the following reasons for downgrading confidence in the evidence (downgraded by 1 or 2): Study limitation (observational studies start with a low GRADE value), Inconsistency (individual studies do not come to the same conclusions or there is only one study so inconsistency cannot be evaluated), Imprecision (there is no effect estimate, there is no measure of dispersion, or the CI is very broad); we used the systematic review authors' evaluation for other GRADE criteria if there was a formal quality of evidence assessment (see text).
      Advance directive implementation

      Pediatric

      Multiple settings

      Outcome: treatment decisions
      1 SR
      • Lotz J.D.
      • Jox R.J.
      • Borasio G.D.
      • Fuhrer M.
      Pediatric advance care planning: a systematic review.
      One review concluded that pediatric ACP can facilitate treatment decision making, on the basis of a chart review study reporting that after the implementation of an advanced directive, ventilator support and catecholamines were withdrawn and narcotics added for most patients.
      Advance directive implementation

      Pediatric

      Multiple settings

      Outcome: death at home
      1 SR
      • Lotz J.D.
      • Jox R.J.
      • Borasio G.D.
      • Fuhrer M.
      Pediatric advance care planning: a systematic review.
      One review found two qualitative studies suggesting that pediatric ACP sessions promote home deaths for children.V (S, Im)
      Advance directive implementation

      Pediatric

      Multiple settings

      Outcome: surrogate understanding
      1 SR
      • Lotz J.D.
      • Jox R.J.
      • Borasio G.D.
      • Fuhrer M.
      Pediatric advance care planning: a systematic review.
      One review found evidence from a single RCT that pediatric ACP discussions improved surrogates' understanding of the patient's preferences.V (Im, In)
      Advance directive implementation

      Pediatric

      Multiple settings

      Outcome: quality of communication
      1 SR
      • Lotz J.D.
      • Jox R.J.
      • Borasio G.D.
      • Fuhrer M.
      Pediatric advance care planning: a systematic review.
      One review found evidence from a single RCT that participants in pediatric ACP discussions report higher quality of communication than those who do not participate in ACP discussions.V (Im, In)
      Advance directive implementation

      Pediatric

      Multiple settings

      Outcome: caregiver well-being
      1 SR
      • Lotz J.D.
      • Jox R.J.
      • Borasio G.D.
      • Fuhrer M.
      Pediatric advance care planning: a systematic review.
      One review found a single RCT indicating pediatric ACP triggers positive emotional experiences in surrogates of HIV-infected adolescent patients.V (Im, In)
      Family-centered ACP

      Pediatric

      Multiple settings

      Outcome: treatment decisions
      2 SRs
      • Weaver M.S.
      • Heinze K.E.
      • Kelly K.P.
      • et al.
      Palliative care as a standard of care in pediatric oncology.
      • Weaver M.S.
      • Heinze K.E.
      • Bell C.J.
      • et al.
      Establishing psychosocial palliative care standards for children and adolescents with cancer and their families: an integrative review.
      Two reviews concluded that family-centered ACP increases the likelihood of limiting the use of futile or expensive and invasive treatments at the end of life but did not report effect estimates.L (S, Im)
      Family-centered ACP

      Pediatric

      Multiple settings

      Outcome: decisional conflict
      1 SR
      • Wilkins M.L.
      • Dallas R.H.
      • Fanone K.E.
      • Lyon M.E.
      Pediatric palliative care for youth with HIV/AIDS: systematic review of the literature.
      One review identified a single RCT that reported that family-centered ACP leads to decreased decisional conflict.V (Im, In)
      Family-centered ACP

      Pediatric

      Multiple settings

      Outcome: preference-concordant care
      1 SR
      • Weaver M.S.
      • Heinze K.E.
      • Kelly K.P.
      • et al.
      Palliative care as a standard of care in pediatric oncology.
      One review identified a single longitudinal cohort study reporting that family-centered ACP for children and adolescents with cancer increased the likelihood that patients were more likely to receive end-of-life care that was consistent with their preferences.V (S, Im, In)
      Family-centered ACP

      Pediatric

      Multiple settings

      Outcome: surrogate understanding
      2 SRs
      • Weaver M.S.
      • Heinze K.E.
      • Kelly K.P.
      • et al.
      Palliative care as a standard of care in pediatric oncology.
      • Wilkins M.L.
      • Dallas R.H.
      • Fanone K.E.
      • Lyon M.E.
      Pediatric palliative care for youth with HIV/AIDS: systematic review of the literature.
      Two reviews reported surrogate understanding of the outcomes and found positive effects but did not provide effect estimates. One review identified a longitudinal cohort study reporting that family-centered ACP for children and adolescents with cancer increased family's ability to honor the wishes of their children. Another review identified one RCT of a family-centered ACP intervention for children or adolescents with HIV that found the intervention increased congruence in adolescent/surrogate treatment preferences.L (Im)
      Family-centered ACP

      Pediatric

      Multiple settings

      Outcome: quality of communication
      1 SR
      • Wilkins M.L.
      • Dallas R.H.
      • Fanone K.E.
      • Lyon M.E.
      Pediatric palliative care for youth with HIV/AIDS: systematic review of the literature.
      One RCT of a family-centered ACP intervention for children or adolescents with HIV found that the intervention enhanced quality of communication.V (Im, In)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: treatment decisions
      1 SR
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      • Brinkman-Stoppelenburg A.
      • Rietjens J.A.
      • van der Heide A.
      The effects of advance care planning on end-of-life care: a systematic review.
      • Hickman S.E.
      • Keevern E.
      • Hammes B.J.
      Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature.
      One review noted that most identified non-RCT studies of advance directive or physician order interventions led to decreased use of life-sustaining treatments, decrease in hospitalization, and increased use of hospice and palliative care.L (S, Im)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: preference-concordance
      3 SRs
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      • Brinkman-Stoppelenburg A.
      • Rietjens J.A.
      • van der Heide A.
      The effects of advance care planning on end-of-life care: a systematic review.
      • Hickman S.E.
      • Keevern E.
      • Hammes B.J.
      Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature.
      Three reviews reported preference-concordance outcomes related to advance directive interventions and found positive effects. One review found that patients receiving advance directive interventions with communication had a significantly increased likelihood of receiving end-of-life care in concordance with their preferences compared with control groups (OR 4.66; CI 1.20, 18.08; three RCTs).
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      Another review reported that chart-review and interview data from three studies showing orders documented on a structured advance directive form were largely consistent with patients' expressed preferences. A third review found that advance directive interventions were associated with an increase in compliance with patients' end-of-life wishes in three of four non-RCT studies investigating this effect.
      M (S)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: documentation
      2 SRs
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      • Hickman S.E.
      • Keevern E.
      • Hammes B.J.
      Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature.
      Two reviews found that advance directive–focused interventions increased documentation. One review showed an increased likelihood for the completion of advance directives compared to usual care (OR 3.26; CI 2.00, 5.32; 13 RCTs).
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      Another review found two chart review studies indicating high rates of documentation of end-of-life conversations related to advance directive form completion.
      M (S)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: quality of communication
      1 SR
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      One review found two trials reporting significant results in favor of advance directive interventions for improving quality of communication between patients and health care providers but did not report effect estimates.L (Im)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: decisional conflict/consensus
      1 SR
      • Houben C.H.M.
      • Spruit M.A.
      • Groenen M.T.J.
      • Wouters E.F.M.
      • Janssen D.J.A.
      Efficacy of advance care planning: a systematic review and meta-analysis.
      One review found mixed evidence on the impact of advance directive interventions on decisional conflict and certainty; three identified intervention trials of advance directives demonstrated a decrease in decisional conflict but two other trials found no change in decisional conflict. The review did not report effect estimates.L (Im, In)
      Orders/advance directive

      Adults or mixed samples

      Multiple settings

      Outcome: quality of care/death
      1 SR
      • Brinkman-Stoppelenburg A.
      • Rietjens J.A.
      • van der Heide A.
      The effects of advance care planning on end-of-life care: a systematic review.
      One review concluded that there is mixed evidence that advance directive interventions positively impact the quality of end-of-life care.V (S, Im, In)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: treatment decisions
      4 SRs
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      • Song K.
      • Amatya B.
      • Voutier C.
      • Khan F.
      Advance care planning in patients with primary malignant brain tumors: a systematic review.
      • Jain A.
      • Corriveau S.
      • Quinn K.
      • et al.
      Video decision aids to assist with advance care planning: a systematic review and meta-analysis.
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      Four reviews reported treatment decision outcomes related to the use of decision tools and found mixed evidence. One review reported low-quality evidence that patients receiving video decision tool interventions are less likely to prefer CPR than controls (RR 0.50; CI 0.27, 0.95; seven RCTs) but noted low-quality evidence due to considerable heterogeneity across studies.
      • Jain A.
      • Corriveau S.
      • Quinn K.
      • et al.
      Video decision aids to assist with advance care planning: a systematic review and meta-analysis.
      Three other reviews found that video decision tools were associated with significant increases in the selection of comfort care as primary goal, but none reported effect estimates.
      L (S, In)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: concordance
      2 SRs
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      Two reviews reported patient-surrogate concordance outcomes related to the use of decision tools, but neither reported effect estimates. Both reviews identified the same single RCT of a video tool that significantly increased concordance of surrogate prediction and patient preference.L (Im)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: documentation
      3 SRs
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      • Jain A.
      • Corriveau S.
      • Quinn K.
      • et al.
      Video decision aids to assist with advance care planning: a systematic review and meta-analysis.
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      Three reviews reported on the impact of decision tools on documentation but found mixed evidence. One review concluded that there may be a small effect of decision aids on documentation of advance directives but with a wide CI including no effect (RR 1.1; CI 0.85, 1.46; four RCTs).
      • Jain A.
      • Corriveau S.
      • Quinn K.
      • et al.
      Video decision aids to assist with advance care planning: a systematic review and meta-analysis.
      In another review, four studies were identified showing increased rates of ACP documentation, but two studies showed no change. Another review also found mixed evidence on the positive impact of decision aids on ACP documentation.
      L (S, In)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: quality of communication
      2 SRs
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      Two reviews reported communication outcomes and found mixed evidence, but effect estimates were not reported. One review described three decision tools that were found to improve clinical communication. Another review found two studies demonstrating the positive effect of decision aids on quality and frequency of end-of-life communication, and one study where no change was detected.L (Im, In)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: decisional conflict/consensus
      5 SRs
      • Ostherr K.
      • Killoran P.
      • Shegog R.
      • Bruera E.
      Death in the digital age: a systematic review of information and communication technologies in end-of-life care.
      • Song K.
      • Amatya B.
      • Voutier C.
      • Khan F.
      Advance care planning in patients with primary malignant brain tumors: a systematic review.
      • Cardona-Morrell M.
      • Benfatti-Olivato G.
      • Jansen J.
      • et al.
      A systematic review of effectiveness of decision aids to assist older patients at the end of life.
      • Jain A.
      • Corriveau S.
      • Quinn K.
      • et al.
      Video decision aids to assist with advance care planning: a systematic review and meta-analysis.
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      Five reviews reported decisional conflict outcomes and found mixed evidence on impact. None of the reviews reported effect estimates. One review found three studies reporting improved decisional conflict associated with multicomponent decision aid interventions. Another review reported a single RCT of a video decision aid that led to increased certainty about decision making. One review reported improvements in decisional conflict in eight studies but the reduction was only significant in four studies. Another review reported a single RCT reporting significantly lower decisional uncertainty associated with a video decision aid than control. Another review reported a single high-quality RCT that found no change in decisional conflict associated with a decision aid intervention.L (Im, In)
      Decision tools

      Adults or mixed samples

      Multiple settings

      Outcome: caregiver well-being
      1 SR
      • Austin C.A.
      • Mohottige D.
      • Sudore R.L.
      • Smith A.K.
      • Hanson L.C.
      Tools to Promote shared decision making in serious illness: a systematic review.
      One review found a single RCT reporting the positive impact of a booklet assisting family members with the decision about disclosure of terminal status on caregiver depression.L (Im, In)
      Care planning discussion

      Adults or mixed samples

      Multiple settings

      Outcome: preference-concordance
      1 SR
      • Baidoobonso S.
      Patient care planning discussions for patients at the end of life: an evidence-based analysis.
      A 2014 Health Quality Ontario systematic review found one RCT and two observational studies demonstrating that care planning discussions can increase preference-concordant care (OR: 2.28; CI 1.41, 3.70).
      • Baidoobonso S.
      Patient care planning discussions for patients at the end of life: an evidence-based analysis.
      M (In)
      Care planning discussion

      Adults or mixed samples

      Multiple settings

      Outcome: concordance
      1 SR
      • Baidoobonso S.
      Patient care planning discussions for patients at the end of life: an evidence-based analysis.
      A 2014 Health Quality Ontario systematic review found two RCTs and one observational study demonstrating that care planning discussions are associated with greater concordance between patient and family wishes but did not provide pooled effect estimates.M (Im)
      Care planning discussion

      Adults or mixed samples

      Multiple settings

      Outcome: documentation
      1 SR
      • Baidoobonso S.
      Patient care planning discussions for patients at the end of life: an evidence-based analysis.
      A 2014 Health Quality Ontario systematic review found that based on evidence from one large cluster RCT and two large RCTs, single-provider care planning discussions were associated with a 13% to 77% (95% CIs ranged from 5% to 83%) increase in completion of ACP documents and processes, though results were not pooled because of heterogeneity. The review also reported a large RCT showing that team-based care planning discussions were associated with a 22% (95% CI: 15%, 30%) increase in the completion of ACP processes and documents.M (Im)
      Care planning discussion

      Adults or mixed samples

      Multiple settings

      Outcome: treatment decisions
      1 SR
      • Baidoobonso S.
      Patient care planning discussions for patients at the end of life: an evidence-based analysis.
      One review noted that patients who had care planning discussions with a single provider were less likely to be resuscitated (two observational studies) and more likely to receive hospice care (one RCT) than those who did not participate in care planning discussions.L (Im)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: documentation
      2 SRs
      • MacKenzie M.A.
      • Smith-Howell E.
      • Bomba P.A.
      • Meghani S.H.
      Respecting choices and related models of advance care planning: a systematic review of published evidence.
      • Myers J.
      • Cosby R.
      • Gzik D.
      • et al.
      Provider tools for advance care planning and goals of care discussions: a systematic review.
      Two reviews examined the impact of facilitated ACP on documentation of ACP and reported mixed evidence. One review concluded on the basis of one RCT and seven non-RCT studies that a low level of evidence indicates that facilitated ACP models increase documentation of advance directives and physician orders; another review highlighted the lack of consistent patient outcome evidence to support the use of facilitated ACP models to improve documentation.L (Im, In)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: surrogate understanding
      1 SR
      • MacKenzie M.A.
      • Smith-Howell E.
      • Bomba P.A.
      • Meghani S.H.
      Respecting choices and related models of advance care planning: a systematic review of published evidence.
      One review concluded on the basis of seven RCTs that a high level of evidence demonstrates facilitated ACP models positively impact patient-surrogate congruence but did not provide effect estimates.M (Im)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: preference concordance
      2 SRs
      • MacKenzie M.A.
      • Smith-Howell E.
      • Bomba P.A.
      • Meghani S.H.
      Respecting choices and related models of advance care planning: a systematic review of published evidence.
      • Myers J.
      • Cosby R.
      • Gzik D.
      • et al.
      Provider tools for advance care planning and goals of care discussions: a systematic review.
      Two reviews concluded that evidence is mixed, inconclusive, and too poor in quality to determine whether facilitated ACP models change the consistency of treatment with wishes at the end of life.L (Im, In)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: treatment decisions
      1 SR
      • MacKenzie M.A.
      • Smith-Howell E.
      • Bomba P.A.
      • Meghani S.H.
      Respecting choices and related models of advance care planning: a systematic review of published evidence.
      One review concluded on the basis of two identified implementation studies that evidence is mixed, inconclusive, and too poor in quality to determine whether facilitated ACP models change treatment decisions and health care use at the end of life.V (S, Im, In)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: decisional conflict/consensus
      1 SR
      • Myers J.
      • Cosby R.
      • Gzik D.
      • et al.
      Provider tools for advance care planning and goals of care discussions: a systematic review.
      One review concluded that there is a lack of consistent patient outcome evidence to support any one facilitated ACP intervention as an approach to decreasing decisional conflict.L (Im, In)
      Facilitated ACP

      Adults or mixed samples

      Multiple settings

      Outcome: caregiver well-being
      1 SR
      • Myers J.
      • Cosby R.
      • Gzik D.
      • et al.
      Provider tools for advance care planning and goals of care discussions: a systematic review.
      One review identified an RCT of a facilitated ACP model that demonstrated improvements in symptoms of anxiety and depression among bereaved family caregivers.L (Im, In)
      Statement of future care

      Adults or mixed samples

      Multiple settings

      Outcome: treatment decisions
      1 SR
      • Candy B.
      • Elliott M.
      • Moore K.
      • et al.
      UK quality statements on end of life care in dementia: a systematic review of research evidence.
      One review concluded that there is mixed evidence on the effect of a statement about future care on types of treatment at the EOL.V (S, Im, In)
      Structured communication

      Adults or mixed samples

      Multiple settings

      Outcome: documentation
      2 SRs
      • Field R.A.
      • Fritz Z.
      • Baker A.
      • Grove A.