Early palliative care improves QoL, wellbeing of people with life-limiting illness

Specialist palliative care (SPC) can reasonably enhance the quality of life (QoL) and emotional concerns of individuals with life-limiting illness, regardless of their medical condition, suggests a study. The most effective models of SPC service provision are multidisciplinary, multicomponent, and multi-setting.

“Currently, most SPC referrals occur within weeks of death; our data seriously challenge this practice as too late for optimal benefit,” the investigators said. “Timely involvement in response to relevant concerns at any point during an individual’s illness should be the standard of care.”

A total of 42,787 records were identified, from which 39 randomized controlled trials (RCTs; 38 from high- and middle-income countries) were included in the meta-analysis. [PLoS Med 2024;21:e1004436]

Thirty-three and 22 RCTs assessed QoL and emotional wellbeing. The pooled results showed significant benefit with SPC for QoL from 3 months’ follow-up (13 to 36 weeks: standardized mean difference [SMD] in minimally clinically important difference [MID] units, 0.40, 95 percent confidence interval [CI], 0.21‒0.59; p<0.001; I², 60 percent).

Furthermore, 13 percent of the patients who received SPC intervention experienced an effect of at least 1 MID unit change for QoL (relative risk, 1.13, 95 percent CI, 1.06‒1.20; p<0.001; I², 0 percent), while 16 percent had an effect of at least 1 MID unit change (95 percent CI, 1.08‒1.24; p<0.001; I², 0 percent) for emotional wellbeing.

From 2 weeks to 3 months, the number needed to treat (NNT) improved from 69 to 15 for QoL and from 46 to 28 for emotional wellbeing.

“We were able to demonstrate a moderate effect size for clinically meaningful benefit, in contrast to the uncertainty in previous published evidence syntheses, identify the timescale of expected benefit, and present benefit in a clinically relevant format (the NNT),” the investigators said. [BMC Health Serv Res 2014;14:136; BMJ 2017;357:j2925; JAMA 2020;324:1439-1450]

Early SPC

These results are important given that SPC services are usually provided within the last days and weeks of life, according to the investigators.

In another systematic review involving 169 studies from 23 countries, the median SPC duration before death was only 18.9 days. The duration was much shorter for patients with noncancer diseases (15 days cancer vs 6 days noncancer). [BMC Med 2020;18:368]

Even countries with well-established SPC with national coverage made most referrals less than 3 months before death. However, another study found long-term patient benefit from early SPC, with better QoL at end-of-life than those receiving SPC closer to death. [Int J Environ Res Public Health 2022;19:13017; Palliat Med 2018;32:1322-1333]

“Our data seriously challenge the current practice of referral to SPC close to death,” the investigators said. “Policy and service commissioning should drive needs-based referral at least 3 to 6 months before death as the optimal standard of care.”

In the current study, a systematic review with meta-analysis and meta-regression, the investigators searched the databases of Cochrane, Medline, Cinahl, ICTRP, and clinicaltrials.gov from 1 January 2000 to 28 December 2023, with additional hand searches for conference abstracts.

Two investigators screened studies independently and identified RCTs that compared SPC intervention with usual care in adults with life-limiting disease. Novel methods were used to convert outcomes into MID units and NNT.

Study bias and quality were assessed using the Cochrane Risk of Bias 2 tool and certainty of evidence using the GRADE tool. The investigators performed random-effects meta-analyses and meta-regression to synthesize endpoints between 2 weeks and 12 months for effect of QoL and emotional wellbeing expressed and combined in MID units.