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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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.
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Competing interests: No competing interests