Wisdom and compassion are needed when evidence is lacking

General practice p 1472

In 1994 McWhinney and colleagues reported the failure of an attempt to assess a palliative care home support team using a randomised controlled trial.1 Problems included attrition of study subjects because of early death and difficulties with recruitment, consent to randomisation, data collection, and timing of outcome assessment. In an accompanying editorial McQuay and Moore argued that assessment of palliative care packages by randomised trials remained mandatory despite these difficulties.2 Skating around the ethical problems of randomisation, they restated the evidence movement's demand for proof of effectiveness. Five years down the line, are we any further forward?

Smeenk et al reported a systematic review of the effectiveness of home care programmes for patients with incurable cancer in 1998, finding nine prospective controlled studies (five randomised) which they judged methodologically adequate.3 Eight of the nine studies were from the United States; methodological quality was rated as moderate overall; and, though positive influences on various dimensions of outcome were found in a minority of studies, the overall effectiveness of such programmes was thought to remain unclear.

Today the BMJ publishes a further valiant attempt to conduct a satisfactory randomised trial of a home …