Palliative Care Improves QOL but Not Survival

Fran Lowry

November 22, 2016

A huge meta-analysis involving nearly 13,000 patients with life-threatening illnesses (cancer, heart failure) and a smaller study of patients undergoing hematopoietic stem cell transplant (HeCT) have both shown that palliative care improves quality of life (QOL) but does not prolong survival.

The studies were published online November 22 in JAMA.

Both studies demonstrate the benefit of palliative care and underscore the imperative to train clinicians to deliver effective palliative care interventions, write editorialists Preeti N. Malani, MD, University of Michigan Health System, Ann Arbor, and Eric Widera, MD, University of California, San Francisco, in an accompanying editorial.

The editorialists highlight the increase in palliative care programs that has occurred in recent years. In 1998, only 15% of US hospitals with 50 beds or more had formal palliative care programs. By 2013, the proportion had increased to 67%. Among larger hospitals ― those with more than 300 beds ― 90% now have palliative care programs.

"This expansion coincides with a growing body of high-quality evidence that supports the early involvement of palliative care specialists, even from the time a serious illness is initially diagnosed," the editorialists write.

This view concurs with that expressed in the recently updated palliative care guidelines released by the American Society of Clinical Oncology (ASCO) and reported by Medscape Medical News.

The new ASCO palliative care guidelines stress that palliative care should begin as soon as a patient's cancer becomes advanced.

Strong Evidence for PC Benefits

In their editorial, Dr Malani and Dr Widera emphasize the importance of training both specialists and nonspecialists to provide palliative care.

"A multipronged approach, such as the Palliative Care and Hospice Education and Training Act (PCHETA), provides a road map for how to accomplish this goal," they write.

"Along with expanding palliative care research and public awareness, PCHETA is designed to establish a nationwide network of palliative care and hospice education centers that could expand specialist training programs and also train all clinicians in providing high-quality palliative care. With estimated expenditures of up to $49.1 million per year, the cost of PCHETA is small compared with the potential benefits of meaningfully improving the QOL of individuals living with serious illness," they conclude

Large Meta-analysis Finds Important Benefits

The meta-analysis, led by Dio Kavalieratos, PhD, University of Pittsburgh, in Pennsylvania, examined the association of palliative care with QOL, symptom burden, survival, and other outcomes for people with life-limiting illness. It also assessed similar outcomes for the patients' caregivers.

The meta-analysis included 43 randomized controlled trials (RCTs) that provided information on 12,731 patients (mean age, 67 years) and 2479 caregivers.

Most of the trials (30 of 43, 69.7%) included patients with cancer; 14 trials (32.5%) included patients with heart failure. These two diseases are those that most commonly necessitate palliative care, the authors note.

Of the 43 RCTs, 35 used usual care as the control; 14 took place in an ambulatory setting.

The analysis showed that palliative care was associated with statistically and clinically significant improvements in patient QOL at 1 and 3 months' follow-up, as well as improvements in symptom burden.

When the five RCTs in which there was a low risk for bias were taken into account, the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% confidence interval [CI], 0.06 - 0.34).

The association with symptom burden did not remain statistically significant (standardized mean difference, -0.21; 95% CI, -0.42 to 0.00).

Although QOL improved, the analysis found no association between palliative care and survival (hazard ratio [HR], 0.90; 95% CI, 0.69 - 1.17).

The analysis also found that palliative care was consistently associated with improvements in advance care planning, patient and caregiver satisfaction, and lower healthcare utilization.

Evidence of associations with other outcomes, such as site of death, patient mood, and healthcare expenditure, was mixed, as was the association with caregiver outcomes.

Dr Kavalieratos and colleagues suggest three explanations for the mixed result concerning caregiver outcomes.

They write: "...many of the reviewed interventions did not specifically target caregivers. Included trials were typically patient focused. Second, of palliative care interventions that targeted caregivers, there was considerable variability in their type and delivery. Third, care needs of patients with life-limiting illness change as patient health deteriorates. Hence, despite training in coping skills, caregivers may feel burdened by having to adapt to these changing needs."

PC Improves QOL in HCT Inpatients

The second study, led by Areej El-Jawahri, MD, Massachusetts General Hospital and Harvard Medical School, Boston, found that palliative care for patients undergoing HCT resulted in a smaller decrease in QOL than was seen in patients who did not receive palliative care.

This study assessed the effect of inpatient palliative care on QOL 2 weeks after HCT among 160 patients at Massachusetts General Hospital. Patients randomly assigned to an inpatient palliative care intervention (n = 81) reported a 14.72-point decrease in their QOL from the time of admission for HCT to week 2 of hospitalization. This compares with a 21.54-point decrease in QOL for patients (n = 79) assigned to routine transplant care alone.

The study found no significant differences in caregiver outcomes with regard to overall QOL and anxiety. However, caregivers of the patients who received palliative care reported improvement in coping and in administrative and financial QOL domains.

Dr Eahri and colleagues write that palliative care may help to lessen the decline in QOL experienced by patients during hospitalization for HCT, "which has long been perceived as a natural aspect of the transplantation process."

Dr Kavalieratos, Dr El-Jahwari, and Dr Malani report no relevant financial relationships. Dr Widera is a board member of the American Academy of Hospice and Palliative Care Medicine.

JAMA. Published online November 22, 2016.

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