Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review.

BACKGROUND: Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. OBJECTIVES: To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. DESIGN: Systematic review. STUDY SELECTION: English-language articles analyzing multicomponent palliative care interventions. OUTCOMES MEASURED: Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). RESULTS: Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. CONCLUSIONS: While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.

Why is high-quality research on palliative care so hard to do? Barriers to improved research from a survey of palliative care researchers.

BACKGROUND: Substantial agreement has been achieved on research priorities in palliative care over the past 15 years, as evidenced by consensus conferences and systematic reviews. Despite the presence of a widely endorsed research agenda, however, addressing the gaps in scientific knowledge has progressed slowly, suggesting that researchers face significant obstacles to conducting high-quality research on the most pressing topics in the field. OBJECTIVE: To systematically identify barriers to improved and expanded palliative care research as reported by researchers. DESIGN: Semistructured telephone interviews to solicit barriers to research in palliative care. SETTING/SUBJECTS: A purposive, interdisciplinary sample of 61 leading researchers in palliative care. MEASUREMENTS: Interviews were transcribed and analyzed using standard qualitative methods. RESULTS: Respondents named five barriers impeding progress: (1) funding, (2) institutional capacity, (3) researcher workforce, (4) challenges related to the topic and population (e.g., attrition, heightened human subjects protections), and (5) public and professional misunderstanding of palliative care and aversion to topics related to serious illness and end-of-life. CONCLUSIONS: Research in palliative care is being held back by significant barriers that require the attention of institutions and funders. The consensus within the interdisciplinary sample indicates that concentrated effort to address barriers related to funding and researcher workforce could facilitate progress on established research priorities. More research is needed on viable strategies for overcoming the identified barriers.

Dyspnea in palliative care: expanding the role of corticosteroids.

Dyspnea is one of the most common symptoms in advanced cancer patients at the end of their life. It is often multifactorial with diverse malignant, nonmalignant, and cancer treatment related etiologies. Oxygen, opiates, and anxiolytics are commonly administered. Here a complex case of progressive dyspnea and its treatments in a patient with advanced pancreatic cancer is described, and its multiple potential contributing causes are identified and clinical responses evaluated. Literature review is conducted on pulmonary drug toxicity and tumor lymphangitic spread, and the role of corticosteroids in relieving dyspnea in the palliative care setting.