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-analysisBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2925 (Published 04 July 2017) Cite this as: BMJ 2017;357:j2925
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Re: 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
I read with great interest Gaertner’s meta-analysis on the effectiveness of specialist palliative care services on quality of life in adults with advanced incurable illness (1). We all believe that assessing the power of a palliative care intervention has a great value. Recent studies showed an improvement of quality of life, in mood, lower frequency of agressive therapeutics near end-of-life, and even a better survival in patients with advanced cancers who benefited from an early integrative intervention by a palliative care team (2) (3). In that study, the analyses of quality of life were re-expressed on the global health/QoL scale of the European Organization for Research and Treatment of Cancer QLQ-C30.
Patients with advanced disease are a particular population, whose general condition is often altered. The European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire is a common questionnaire used to assess quality of life of cancer patients through 30 items. The length of the questionnaire may be excessive and some items may be inappropriate for palliative patients. Therefore two specific questionnaires have been validated for use in this population. On the one hand the FACIT-Pal questionnaire which is a 46-item composed of the core Functional Assessment of Cancer Therapy – General and a 19-item palliative subscale, the QLQ-C15-PAL on the other hand is a shorter version of the longer core questionnaire the EORTC Quality of Life Questionnaire Core 30 (4).
In Gaertner’s review, no study included measured quality of life through one of these two specific and validated tools.
Due to its relative brevity EORTC QLQ-C15-PAL questionnaire offers a better compliance and workability. It can be used associated with disease-specific tools such as QLQ-FA12 cancer related fatigue module to detail the assessment without being too exhausting for the patient to complete. (5) (6)
Given the greater simplicity of EORTC QLQ-C15-PAL questionnaire in palliative care patients, it would have been more appropriate to use this questionnaire as a tool for assessing quality of life after palliative management in patients with advanced incurable illness.
Nevertheless, the results of this work require a deep analysis and reflection at a time when it is increasingly recommended to have early recourse to palliative care. We may legitimately ask whether Temel was not ambitious enough and should have simply shown an increasing in overall survival in patients with advanced cancer who benefited from early palliative care. Actually assessing overall survival does not require the use of any scale.
1. Gaertner J, Siemens W, Meerpohl JJ, Antes G, Meffert C, Xander C, 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. BMJ. 2017 Jul 4;357:j2925.
2. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733–42.
3. Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, et al. Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. J Clin Oncol. 2017 Mar 10;35(8):834–41.
4. Lien K, Zeng L, Nguyen J, Cramarossa G, Culleton S, Caissie A, et al. Comparison of the EORTC QLQ-C15-PAL and the FACIT-Pal for assessment of quality of life in patients with advanced cancer. Expert Rev Pharmacoecon Outcomes Res. 2011 Oct;11(5):541–7.
5. Groenvold M, Petersen MA, Aaronson NK, Arraras JI, Blazeby JM, Bottomley A, et al. EORTC QLQ-C15-PAL: the new standard in the assessment of health-related quality of life in advanced cancer? Palliat Med. 2006 Mar;20(2):59–61.
6. Echteld MA, Deliens L, Onwuteaka-Philipsen B, Klein M, van der Wal G. EORTC QLQ-C15-PAL: the new standard in the assessment of health-related quality of life in advanced cancer? Palliat Med. 2006 Jan;20(1):1–2.
Competing interests: No competing interests
I read with great interest Gaertner's review on specialist palliative care (SPC) highlighting the importance of multidisciplinary care. According to the authors' definition, SPC should be coordinated across at least two professions. The professionals involved, as described in the ten RCTs discussed in the article, are often nurses, nurse practitioners, social workers, physical therapists, chaplains, and case managers. Such approaches are not uncommon. For example, implementing multidisciplinary care and rounds may improve perioperative outcomes. Such quality improvement initiatives were usually effective in a single centre. However, benefits of these multidisciplinary approaches were less likely to appear when multiple sites were included. Examples can be found in COPD and dementia management. This is probably because the variation of inter-professional care is more attributable to organizational and leadership support rather than spatial characteristics or relationships amongst providers. Transforming the value of integrated care may require a reconfiguration of care delivery beyond a written study protocol alone. It may be difficult in a clinical trial to reconstruct in a short time the culture and leadership, which are essential portions of the true intervention effect in quality improvement studies. Researchers may be confident in controlling for these factors in a single-centre study. However, when all similar studies are joined together, researchers are likely unaware of the impact of these insidious factors.
These multidisciplinary interventions raise another question. Does the benefit come from palliative care professionals or the teamwork—or even any other professional in the team? The real difference in received care between the intervention and control groups has tremendous influence on conclusions that can be made.
Nevertheless, no attempt at quality improvement should be discouraged.
1. Gaertner J, Siemens W, Meerpohl JJ, 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. BMJ 2017;357:j2925.
2. Ravikumar TS, Sharma C, Marini C, et al. A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts. Annals of surgery 2010;252(3):486-96.
3. Kruis AL, Boland MR, Assendelft WJ, et al. Effectiveness of integrated disease management for primary care chronic obstructive pulmonary disease patients: results of cluster randomised trial. BMJ 2014;349:g5392.
4. Bekelman DB, Plomondon ME, Carey EP, et al. Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial. JAMA internal medicine 2015;175(5):725-32.
5. Gonzalo JD, Himes J, McGillen B, Shifflet V, Lehman E. Interprofessional collaborative care characteristics and the occurrence of bedside interprofessional rounds: a cross-sectional analysis. BMC health services research 2016;16:459.
Competing interests: No competing interests