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Palliative Care Interventions for Surgical Patients A Systematic Review

Elizabeth J. Lilley, MD, MPH1,2; Kashif T. Khan, MD3,4; Fabian M. Johnston, MD, MHS5; Ana Berlin, MD, MPH6; Angela M. Bader, MD, MPH1,4,7,8; Anne C. Mosenthal, MD6; Zara Cooper, MD, MSc1,3,8
[+] Author Affiliations
1Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
2Department of Surgery, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey
3Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
4Harvard School of Public Health, Boston, Massachusetts
5Department of Surgery, Medical College of Wisconsin, Milwaukee
6Department of Surgery, Rutgers–New Jersey Medical School, Newark
7Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
8Department of Surgery, Harvard Medical School, Boston, Massachusetts
JAMA Surg. 2016;151(2):172-183. doi:10.1001/jamasurg.2015.3625.
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Importance  Inpatient palliative care improves symptom management and patient satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined.

Objective  To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients.

Evidence Review  This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015.

Findings  A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes.

Conclusions and Relevance  The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed.

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Flowchart of Literature Search Strategy

Inclusion criteria for eligibility consisted of palliative care intervention; experimental, quasi-experimental, or observational design; adult patients (aged >18 years); more than 20% surgical patients; peer review; and measurement of more than 1 patient-oriented outcome. Exclusion criteria consisted of single palliative surgical procedure; acute postoperative pain intervention; complementary and alternative medicine; full text not available in English; no control or comparison group; and review, editorial, abstract, or conference proceedings.

aArticles were identified from PubMed (n = 1963), EMBASE (n = 1283), CINAHL (n = 1051), and PsycINFO (n = 429).

bTotal does not equal 52 because all reasons for exclusion were given, and some articles had more than one.

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