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A Systematic Review

Camilla Zimmermann, MD, MSc; Rachel Riechelmann, MD; Monika Krzyzanowska, MD, MPH; Gary Rodin, MD; Ian Tannock, MD, PhD

JAMA. 2008;299(14):1698-1709.

Context  Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality.

Objective  To systematically review the evidence for effectiveness of specialized palliative care.

Data Sources  We performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials.

Study Selection  We included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost.

Data Extraction  Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria.

Results  Of 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence.

Conclusions  The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.

Author Affiliations: Division of Medical Oncology and Hematology, Department of Medicine (Drs Zimmermann, Krzyzanowska, and Tannock) and Department of Psychiatry (Drs Zimmermann and Rodin), University of Toronto; Department of Psychosocial Oncology and Palliative Care (Drs Zimmermann and Rodin) and Department of Medical Oncology (Drs Krzyzanowska and Tannock), Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada; and Department of Medical Oncology, Albert Einstein Hospital, Sao Paulo, Brazil (Dr Riechelmann).

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