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Original Investigation
November 22/29, 2016

Association Between Palliative Care and Patient and Caregiver OutcomesA Systematic Review and Meta-analysis

Author Affiliations
  • 1Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
  • 4Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5School of Nursing, University of Alabama at Birmingham
  • 6Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 7Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
  • 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 9College of Science, Virginia Tech, Blacksburg
  • 10Division of Endocrinology, Department of Medicine, University of Pittsburgh, Pittsburgh
JAMA. 2016;316(20):2104-2114. doi:10.1001/jama.2016.16840
Key Points

Question  Is palliative care associated with improved patient and caregiver outcomes?

Findings  In this meta-analysis of randomized clinical trials, palliative care was associated with improvements in quality of life and symptom burden but not with improved survival. However, results were attenuated and some of these associations were no longer statistically significant when analyses were restricted to trials at low risk of bias.

Meaning  Palliative care may be associated with improved quality of life and symptom burden for patients, but findings for caregiver outcomes were mixed. However, the quality of evidence is limited.

Abstract

Importance  The use of palliative care programs and the number of trials assessing their effectiveness have increased.

Objective  To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers.

Data Sources  MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL to July 2016.

Study Selection  Randomized clinical trials of palliative care interventions in adults with life-limiting illness.

Data Extraction and Synthesis  Two reviewers independently extracted data. Narrative synthesis was conducted for all trials. Quality of life, symptom burden, and survival were analyzed using random-effects meta-analysis, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy–palliative care scale (FACIT-Pal) instrument (range, 0-184 [worst-best]; minimal clinically important difference [MCID], 9 points); and symptom burden translated to the Edmonton Symptom Assessment Scale (ESAS) (range, 0-90 [best-worst]; MCID, 5.7 points).

Main Outcomes and Measures  Quality of life, symptom burden, survival, mood, advance care planning, site of death, health care satisfaction, resource utilization, and health care expenditures.

Results  Forty-three RCTs provided data on 12 731 patients (mean age, 67 years) and 2479 caregivers. Thirty-five trials used usual care as the control, and 14 took place in the ambulatory setting. In the meta-analysis, palliative care was associated with statistically and clinically significant improvements in patient QOL at the 1- to 3-month follow-up (standardized mean difference, 0.46; 95% CI, 0.08 to 0.83; FACIT-Pal mean difference, 11.36] and symptom burden at the 1- to 3-month follow-up (standardized mean difference, −0.66; 95% CI, −1.25 to −0.07; ESAS mean difference, −10.30). When analyses were limited to trials at low risk of bias (n = 5), the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% CI, 0.06 to 0.34; FACIT-Pal mean difference, 4.94), whereas the association with symptom burden was not statistically significant (standardized mean difference, −0.21; 95% CI, −0.42 to 0.00; ESAS mean difference, −3.28). There was no association between palliative care and survival (hazard ratio, 0.90; 95% CI, 0.69 to 1.17). Palliative care was associated consistently with improvements in advance care planning, patient and caregiver satisfaction, and lower health care utilization. Evidence of associations with other outcomes was mixed.

Conclusions and Relevance  In this meta-analysis, palliative care interventions were associated with improvements in patient QOL and symptom burden. Findings for caregiver outcomes were inconsistent. However, many associations were no longer significant when limited to trials at low risk of bias, and there was no significant association between palliative care and survival.

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