Featured Review: Hospital-based specialist palliative care for adults with a terminal illness

An elderly couple sit in a park, one person in a wheelchair, the other on a bench

How effective is hospital-based specialist palliative care for adults with a terminal illness and their unpaid caregivers, and is it cost-effective?

Why is this question important?

 Palliative care aims to improve the quality of life of people who have a terminal illness (a disease that cannot be cured and is likely to lead to death). It seeks to help patients, their unpaid caregivers and families manage symptoms that cause distress (for example, pain) and to meet patients’ and unpaid caregivers’ needs for psychological, social and spiritual support. Palliative care is known as an ‘holistic’ approach, because it considers the ‘whole’ person and their support network – not just the illness and its symptoms. It usually involves a team of people that can include physicians, nurses, pharmacists, other allied health professionals, social workers, chaplains or volunteers.

A growing number of hospitals are setting up specialist palliative care services (known as hospital-based specialist palliative care (HSPC)). HSPC can be provided:

  • either in the hospital itself – for inpatients or outpatients;
  • or as 'hospital-at-home' – which means that the hospital team visits patients in the community;
  • or across multiple settings (for example, hospital and home).

To find out whether HSPC benefits patients and their unpaid caregivers, and how cost-effective it is, the author team reviewed the evidence from research.

How did the authors identify and evaluate the evidence?

First, they searched for all relevant studies in the medical literature. They specifically looked for:

  • randomised controlled studies: these are studies where people are randomly divided into different treatment groups. This type of study provides the most robust evidence about the effects of a treatment;
  • studies that compared HSPC to either hospital care without specialist palliative care; care received in the community; or hospice care outside hospital.

The review authors then compared the results, and summarised the evidence from all the studies. Finally, they assessed how certain the evidence was. They considered factors such as the way studies were conducted, study sizes, and consistency of findings across studies. Based on the assessments of the author team, they categorised the evidence as being of very low, low, moderate or high certainty.

What did authors find?

42 studies that involved a total of 6678 patients and 1101 caregivers or family members.

The evidence from the studies found suggests that, when compared to usual care:

  • HSPC may slightly improve patients’ health-related quality of life, their overall symptom burden and their satisfaction with care;
  • HSPC may increase the chances of people dying in their preferred place of death. 

It is unclear what the effects of HSPC are on pain, caregivers’ burden, or unwanted events. This is because the evidence  found was not robust (very low-certainty evidence). Similarly, because the evidence relating to costs was of very low certainty, it is unclear how cost-effective HSPC is.

What does this mean?

When compared with usual care, HSPC may slightly improve a patient’s quality of life, symptom burden and their satisfaction with care. It may also increase their chances of dying at home. However, future research is likely to change these findings, since they are based on low-certainty evidence. Further studies are needed to evaluate the effect of HSPC on other outcomes, such as pain, caregivers’ burden, unwanted events and cost-effectiveness.

How-up-to date is this review?

The evidence in this Cochrane Review is current to August 2019.

Discussing the review, Dr. Sabrina Bajwah, Clinical Senior Lecturer, King’s College London and first author of this review, explains, "Population-based projections have indicated that palliative care needs will increase in the future. Whilst we should interpret the results with caution, our systematic review provides clinicians, policy makers and funders with some clarity on the benefits of hospital palliative care. This may help make informed decisions when looking to prioritise further commissioning of hospital-based specialist palliative care. It also provides patients and their care givers valuable information to inform treatment choices on how hospital palliative care may be able to help improve patient centred care and increase the chances of dying in their preferred place, which is often at home. The provision of palliative care is an ethical imperative for those unlikely to survive and may have the advantage of diverting dying people away from overburdened hospitals as well as providing the care that people want. These benefits may be especially clinically relevant during pandemics and at an advanced stage of disease." 

Wednesday, September 30, 2020
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