The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic
Identifieur interne : 000953 ( Pmc/Corpus ); précédent : 000952; suivant : 000954The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic
Auteurs : Simon N. Etkind ; Anna E. Bone ; Natasha Lovell ; Rachel L. Cripps ; Richard Harding ; Irene J. Higginson ; Katherine E. SleemanSource :
- Journal of Pain and Symptom Management [ 0885-3924 ] ; 2020.
Abstract
Cases of COVID-19 are escalating rapidly across the globe, with the mortality risk being especially high among those with existing illness and multimorbidity. This study aimed to synthesise evidence for the role and response of palliative care and hospice teams to viral epi/pandemics, to inform the COVID-19 pandemic response. We conducted a rapid systematic review according to PRISMA guidelines in five databases. Of 3094 papers identified, ten were included in this narrative synthesis. Included studies were from West Africa, Taiwan, Hong Kong, Singapore, the United States and Italy. All had an observational design. Findings were synthesised using a previously proposed framework according to ‘systems’ (policies, training and protocols, communication and coordination, data), ‘staff’ (deployment, skill mix, resilience), ‘space’ (community provision, use of technology) and ‘stuff’ (medicines and equipment, personal protective equipment). We conclude that hospice and palliative services have an essential role in the response to COVID-19 by: 1) responding rapidly and flexibly; 2) ensuring protocols for symptom management are available, and training non-specialists in their use; 3) being involved in triage; 4) considering shifting resources into the community; 5) considering redeploying volunteers to provide psychosocial and bereavement care; 6) facilitating camaraderie among staff and adopt measures to deal with stress; 7) using technology to communicate with patients and carers; 8) adopting standardised data collection systems to inform operational changes and improve care.
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DOI: 10.1016/j.jpainsymman.2020.03.029
PubMed: 32278097
PubMed Central: 7141635
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic</title><author><name sortKey="Etkind, Simon N" sort="Etkind, Simon N" uniqKey="Etkind S" first="Simon N." last="Etkind">Simon N. Etkind</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Bone, Anna E" sort="Bone, Anna E" uniqKey="Bone A" first="Anna E." last="Bone">Anna E. Bone</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Lovell, Natasha" sort="Lovell, Natasha" uniqKey="Lovell N" first="Natasha" last="Lovell">Natasha Lovell</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Cripps, Rachel L" sort="Cripps, Rachel L" uniqKey="Cripps R" first="Rachel L." last="Cripps">Rachel L. Cripps</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Harding, Richard" sort="Harding, Richard" uniqKey="Harding R" first="Richard" last="Harding">Richard Harding</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Higginson, Irene J" sort="Higginson, Irene J" uniqKey="Higginson I" first="Irene J." last="Higginson">Irene J. Higginson</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Sleeman, Katherine E" sort="Sleeman, Katherine E" uniqKey="Sleeman K" first="Katherine E." last="Sleeman">Katherine E. Sleeman</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32278097</idno><idno type="pmc">7141635</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141635</idno><idno type="RBID">PMC:7141635</idno><idno type="doi">10.1016/j.jpainsymman.2020.03.029</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000953</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000953</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic</title><author><name sortKey="Etkind, Simon N" sort="Etkind, Simon N" uniqKey="Etkind S" first="Simon N." last="Etkind">Simon N. Etkind</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Bone, Anna E" sort="Bone, Anna E" uniqKey="Bone A" first="Anna E." last="Bone">Anna E. Bone</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Lovell, Natasha" sort="Lovell, Natasha" uniqKey="Lovell N" first="Natasha" last="Lovell">Natasha Lovell</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Cripps, Rachel L" sort="Cripps, Rachel L" uniqKey="Cripps R" first="Rachel L." last="Cripps">Rachel L. Cripps</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Harding, Richard" sort="Harding, Richard" uniqKey="Harding R" first="Richard" last="Harding">Richard Harding</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Higginson, Irene J" sort="Higginson, Irene J" uniqKey="Higginson I" first="Irene J." last="Higginson">Irene J. Higginson</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author><author><name sortKey="Sleeman, Katherine E" sort="Sleeman, Katherine E" uniqKey="Sleeman K" first="Katherine E." last="Sleeman">Katherine E. Sleeman</name><affiliation><nlm:aff id="aff1">King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Pain and Symptom Management</title><idno type="ISSN">0885-3924</idno><idno type="eISSN">1873-6513</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Cases of COVID-19 are escalating rapidly across the globe, with the mortality risk being especially high among those with existing illness and multimorbidity. This study aimed to synthesise evidence for the role and response of palliative care and hospice teams to viral epi/pandemics, to inform the COVID-19 pandemic response. We conducted a rapid systematic review according to PRISMA guidelines in five databases. Of 3094 papers identified, ten were included in this narrative synthesis. Included studies were from West Africa, Taiwan, Hong Kong, Singapore, the United States and Italy. All had an observational design. Findings were synthesised using a previously proposed framework according to ‘systems’ (policies, training and protocols, communication and coordination, data), ‘staff’ (deployment, skill mix, resilience), ‘space’ (community provision, use of technology) and ‘stuff’ (medicines and equipment, personal protective equipment). We conclude that hospice and palliative services have an essential role in the response to COVID-19 by: 1) responding rapidly and flexibly; 2) ensuring protocols for symptom management are available, and training non-specialists in their use; 3) being involved in triage; 4) considering shifting resources into the community; 5) considering redeploying volunteers to provide psychosocial and bereavement care; 6) facilitating camaraderie among staff and adopt measures to deal with stress; 7) using technology to communicate with patients and carers; 8) adopting standardised data collection systems to inform operational changes and improve care.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Powell, R A" uniqKey="Powell R">R.A. Powell</name></author><author><name sortKey="Schwartz, L" uniqKey="Schwartz L">L. Schwartz</name></author><author><name sortKey="Nouvet, E" uniqKey="Nouvet E">E. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Pain Symptom Manage</journal-id><journal-id journal-id-type="iso-abbrev">J Pain Symptom Manage</journal-id><journal-title-group><journal-title>Journal of Pain and Symptom Management</journal-title></journal-title-group><issn pub-type="ppub">0885-3924</issn><issn pub-type="epub">1873-6513</issn><publisher><publisher-name>Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32278097</article-id><article-id pub-id-type="pmc">7141635</article-id><article-id pub-id-type="publisher-id">S0885-3924(20)30182-2</article-id><article-id pub-id-type="doi">10.1016/j.jpainsymman.2020.03.029</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Etkind</surname><given-names>Simon N.</given-names></name><degrees>MB BChir BA MRCP DTMH</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Bone</surname><given-names>Anna E.</given-names></name><degrees>PhD MPH BA</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Lovell</surname><given-names>Natasha</given-names></name><degrees>MBChB BSc MRCP</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Cripps</surname><given-names>Rachel L.</given-names></name><degrees>MSc BSc</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Harding</surname><given-names>Richard</given-names></name><degrees>BSc MSc DipSW PhD</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Higginson</surname><given-names>Irene J.</given-names></name><degrees>OBE BMedSci BMBS PhD FMedSci FRCP FFPHM</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au7"><name><surname>Sleeman</surname><given-names>Katherine E.</given-names></name><degrees>BSc MBBS MRCP PhD</degrees><email>Katherine.Sleeman@kcl.ac.uk</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib></contrib-group><aff id="aff1"><label>1</label>King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding Author: Dr Katherine E Sleeman, King’s College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ. <email>Katherine.Sleeman@kcl.ac.uk</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>8</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>8</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>26</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>27</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><p>Cases of COVID-19 are escalating rapidly across the globe, with the mortality risk being especially high among those with existing illness and multimorbidity. This study aimed to synthesise evidence for the role and response of palliative care and hospice teams to viral epi/pandemics, to inform the COVID-19 pandemic response. We conducted a rapid systematic review according to PRISMA guidelines in five databases. Of 3094 papers identified, ten were included in this narrative synthesis. Included studies were from West Africa, Taiwan, Hong Kong, Singapore, the United States and Italy. All had an observational design. Findings were synthesised using a previously proposed framework according to ‘systems’ (policies, training and protocols, communication and coordination, data), ‘staff’ (deployment, skill mix, resilience), ‘space’ (community provision, use of technology) and ‘stuff’ (medicines and equipment, personal protective equipment). We conclude that hospice and palliative services have an essential role in the response to COVID-19 by: 1) responding rapidly and flexibly; 2) ensuring protocols for symptom management are available, and training non-specialists in their use; 3) being involved in triage; 4) considering shifting resources into the community; 5) considering redeploying volunteers to provide psychosocial and bereavement care; 6) facilitating camaraderie among staff and adopt measures to deal with stress; 7) using technology to communicate with patients and carers; 8) adopting standardised data collection systems to inform operational changes and improve care.</p></abstract><kwd-group id="kwrds0010"><title>Key words</title><kwd>COVID-19</kwd><kwd>coronavirus</kwd><kwd>pandemic</kwd><kwd>palliative care</kwd><kwd>hospice</kwd><kwd>end of life</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Key message</title><p id="p0010">An evidence synthesis on the role and response of hospice and palliative care in epi/pandemics, to inform response to COVID-19. Hospice and palliative care services should: respond rapidly and flexibly; produce protocols; shift resources to the community; redeploy volunteers; facilitate staff camaraderie; communicate with patients/carers via technology; standardise data collection.</p></sec><sec id="sec2"><title>Introduction</title><p id="p0015">The relief of suffering, supporting complex decision-making, and managing clinical uncertainty are key attributes of palliative care and essential components of the response to epidemics and pandemics.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> The COVID-19 pandemic is escalating rapidly across the globe. Those affected experience symptoms including breathlessness, cough, myalgia and fever. The mortality risk is especially high among those with existing illness and multimorbidity.</p><p id="p0020">Pandemics such as that caused by COVID-19 can lead to a surge in demand for health care services, including palliative and end of life care.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> These services must respond rapidly, adopting new ways of working as resources are suddenly stretched beyond their normal bounds. Globally, palliative care is now seen as an essential part of Universal Health Coverage. To inform the palliative care response to the COVID-19 pandemic, we aimed to rapidly synthesise evidence on the role and response of palliative care and hospice services to viral epi/pandemics.</p></sec><sec id="sec3"><title>Methods</title><sec id="sec3.1"><title>Design</title><p id="p0025">Rapid systematic review according to PRISMA guidelines.</p></sec><sec id="sec3.2"><title>Inclusion/exclusion criteria</title><p id="p0030"><list list-type="simple" id="ulist0010"><list-item id="u0010"><label>•</label><p id="p0035">Population – Patients, carers, health care professionals, other experts, wards, units, services</p></list-item><list-item id="u0015"><label>•</label><p id="p0040">Intervention – palliative care, hospice care, end of life care, supportive care</p></list-item><list-item id="u0020"><label>•</label><p id="p0045">Context - Viral epidemics or pandemics characterised by rapid transmission through the population and requiring a rapid response from the health system, including Ebola, SARS, MERS, Avian influenza, and COVID-19. HIV was excluded due to its slower transmission through the population.</p></list-item><list-item id="u0025"><label>•</label><p id="p0050">Findings – Role and/or response of palliative care and hospice services</p></list-item><list-item id="u0030"><label>•</label><p id="p0055">Study design - Case studies, cross-sectional studies, cohort studies and intervention studies (opinion pieces and editorials excluded)</p></list-item><list-item id="u0035"><label>•</label><p id="p0060">Language – no limits</p></list-item></list></p></sec><sec id="sec3.3"><title>Search Strategy</title><p id="p0065">We searched five databases (MEDLINE (1966-2019), EMBASE (1980-2019), PsycINFO (1967-2019), CINAHL (1982-2019) and Web of Science (1970-2019)). The search strategy comprised 1) terms for palliative care, hospice care and end of life care, and 2) terms for pandemics and epidemics including specific named pandemics. (<xref rid="appsec1" ref-type="sec">Appendix A</xref>). We identified and screened the reference lists of relevant systematic reviews, government and NGO reports, opinion pieces, and included papers.</p></sec><sec id="sec3.4"><title>Study Selection</title><p id="p0070">One researcher (SNE) completed all searches and removed duplicate records. Papers were screened in EndNote using titles and abstracts by RLC, KES and SNE. Full texts were screened by KES and NL.</p></sec><sec id="sec3.5"><title>Data Extraction</title><p id="p0075">A bespoke data extraction form was created in Excel. Data were extracted by two researchers (KES and NL) and checked by a third (AEB). We did not appraise the quality of included studies.</p></sec><sec id="sec3.6"><title>Analysis</title><p id="p0080">We conducted narrative synthesis, and used the framework proposed by Downar and Seccareccia to group recommendations.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> This framework, based on an established model of Intensive Care surge capacity, suggests that a palliative pandemic plan should include focus on ‘systems’, ‘space’, ‘staff’ and ‘stuff’.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref></p></sec></sec><sec id="sec4"><title>Results</title><p id="p0085">We identified 3088 papers from database searches (search date 18<sup>th</sup> March 2020) and identified six additional papers through screening the reference lists of relevant papers and reports. After removing duplicates 2207 papers remained. 36 papers underwent full text review, and 10 were included in the analysis (<xref rid="fig1" ref-type="fig">Figure 1</xref>, <xref rid="tbl1" ref-type="table">Table 1</xref>).<fig id="fig1"><label>Figure 1</label><caption><p>PRISMA flow chart</p></caption><graphic xlink:href="gr1_lrg"></graphic></fig><table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>Description of included studies</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Authors, year</th><th>Context</th><th>Study Aim</th><th>Study Design</th><th>Setting/Participants</th><th>Findings and author recommendations</th></tr></thead><tbody><tr><td>Costantini et al., 2020<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref></td><td>Italy, Coronavirus (COVID-19)</td><td>To examine the preparedness for and impact of COVID-19 on hospices in Italy to help inform the responses of other countries</td><td>Cross sectional telephone survey</td><td>16 hospices</td><td>Hospice response to COVID-19:<list list-type="simple" id="ulist0015"><list-item id="u0040"><label>•</label><p id="p0185">All hospices had rapidly implemented changes in practice including transfer of staff to community settings, changes in admission criteria and daily telephone support for families.</p></list-item><list-item id="u0045"><label>•</label><p id="p0190">Lack of personal protective equipment</p></list-item><list-item id="u0050"><label>•</label><p id="p0195">Lack of hospice-specific guidance</p></list-item><list-item id="u0055"><label>•</label><p id="p0200">Assessments of risk and potential impact on staff varied greatly.</p></list-item></list>Authors recommended that governments urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the health care system response. Availability of personal protective equipment and setting-specific guidance is essential.</td></tr><tr><td>Battista et al., 2019<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></td><td>West Africa, Ebola Virus Disease (EVD)</td><td>To identify care measures, and barriers and facilitators to their implementation for patients with Ebola Virus Disease</td><td>Cross-sectional online survey</td><td>29 clinicians and decision-makers (24 physicians, 3 nurses and 2 involved in project management and coordination)</td><td>Barriers to the provision of supportive care:<list list-type="simple" id="ulist0020"><list-item id="u0060"><label>•</label><p id="p0205">Insufficient numbers of health workers (maintenance, surveillance, laboratory professionals)</p></list-item><list-item id="u0065"><label>•</label><p id="p0210">Improper tools to document clinical data</p></list-item><list-item id="u0070"><label>•</label><p id="p0215">Insufficient material resources (drug supplies, intravenous catheters and lines)</p></list-item><list-item id="u0075"><label>•</label><p id="p0220">Unadapted personal protective equipment</p></list-item><list-item id="u0080"><label>•</label><p id="p0225">Limited sharing of protocols, advice, and standards of care within organisations</p></list-item></list>Facilitators to the provision of supportive care:<list list-type="simple" id="ulist0025"><list-item id="u0085"><label>•</label><p id="p0230">Team camaraderie</p></list-item><list-item id="u0090"><label>•</label><p id="p0235">Ability to speak the local language</p></list-item><list-item id="u0095"><label>•</label><p id="p0240">Treatment protocols in place</p></list-item></list>Authors recommended that these areas of consensus are incorporated into guidelines to ensure standards of care are met.</td></tr><tr><td>Loignon et al., 2018<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref></td><td>West Africa, Ebola Virus Disease (EVD)</td><td>To document barriers to supportive care in Ebola Treatment Units</td><td>Qualitative telephone interviews</td><td>29 clinicians and decision-makers, comprising 25 physicians, three nurses and one other</td><td>Barriers to the provision of supportive care:<list list-type="simple" id="ulist0030"><list-item id="u0100"><label>•</label><p id="p0245">Lack of material and human resources (access to diagnostic and monitoring equipment)</p></list-item><list-item id="u0105"><label>•</label><p id="p0250">Organisational structure limited the provision of clinical care (lack of protocols, and deficient management structures)</p></list-item><list-item id="u0110"><label>•</label><p id="p0255">Delayed and poorly coordinated policies limited the effectiveness of global and national response (insufficient political leadership and early epidemiological surveillance)</p></list-item></list>Authors recommended that relevant protocols are available and organisational structures are improved to provide supportive care in future outbreaks.</td></tr><tr><td>Dhillon et al., 2015<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref></td><td>West Africa, Ebola Virus Disease (EVD)</td><td>To describe the treatment course of a man admitted to an Ebola Treatment Centre and to describe some of the challenges identified</td><td>Case Report</td><td>One 33 year old man admitted to an Ebola Treatment Centre who died from Ebola related complications 18 days later</td><td>Challenges identified in providing care for an Ebola patient:<list list-type="simple" id="ulist0035"><list-item id="u0115"><label>•</label><p id="p0260">Lack of consistency/continuity of staff</p></list-item><list-item id="u0120"><label>•</label><p id="p0265">A decision maker was not identified</p></list-item><list-item id="u0125"><label>•</label><p id="p0270">No recognition that the patient was dying</p></list-item><list-item id="u0130"><label>•</label><p id="p0275">There was emphasis on saving life and any protocols specific to palliative care were not implemented.</p></list-item></list>Authors recommend that communication is paramount in an environment where there are multiple caregivers, identification of a lead decision maker is helpful, and knowledge of the basics of palliative are essential, particularly in low resource settings.</td></tr><tr><td>Michaels-Strasser et al., 2015<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref></td><td>Sierra Leone, Ebola Virus Disease (EVD)</td><td>To assess the outcome or effectiveness of community care centres for rapid isolation and palliative care of people with suspected Ebola disease</td><td>Cross sectional assessment using direct observation, a site assessment survey, and staff interviews</td><td>11 community care centres and 58 key informants</td><td>Description and assessment of community care centres:<list list-type="simple" id="ulist0040"><list-item id="u0135"><label>•</label><p id="p0280">Centres ranged from tents to repurposed hospital wards and schools and were set up swiftly (median 10 days)</p></list-item><list-item id="u0140"><label>•</label><p id="p0285">Common features were proximity to community, small size (8-28 beds), ability to triage and isolate cases, and transport to Ebola treatment units when beds became available.</p></list-item><list-item id="u0145"><label>•</label><p id="p0290">Community care centres engaged and supported communities and fostered trust.</p></list-item><list-item id="u0150"><label>•</label><p id="p0295">Limited data to assess effectiveness, with registers and forms not standardised</p></list-item></list>Authors recommended that the creation of community care centres could be an effective and scalable response, if they have standardised design, include monitoring and evaluation instruments, and training and supervision manuals.</td></tr><tr><td>Cheng et al., 2014<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></td><td>Hong Kong, Avian Influenza</td><td>To explain measures taken by palliative care services in Hong Kong during the H7N9 Influenza</td><td>Case study of a service</td><td>The first confirmed case of human avian influenza A (H7N9)</td><td>Response to avian influenza within a palliative care unit:<list list-type="simple" id="ulist0045"><list-item id="u0155"><label>•</label><p id="p0300">Visiting hours for palliative units were limited to less than four hours per day, with not more than two visitors per visit.</p></list-item><list-item id="u0160"><label>•</label><p id="p0305">Visitors to public hospitals were required to put on surgical masks and perform hand hygiene before and after visiting patient areas.</p></list-item><list-item id="u0165"><label>•</label><p id="p0310">Volunteer services and clinical attachment in public hospitals were suspended.</p></list-item><list-item id="u0170"><label>•</label><p id="p0315">The palliative unit handled the restriction on family visits on compassionate grounds.</p></list-item></list>Authors highlight the ethical dilemma that arise between dual need for infection control and comprehensive psychosocial care, with volunteers being integral to the interdisciplinary model of palliative care.</td></tr><tr><td>Matzo et al. 2009<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref></td><td>Hypothetical mass casualty event from an influenza pandemic or other event</td><td>To understand the role of palliative care in mass casualty events and to make recommendations</td><td>Qualitative telephone interviews and group meeting with experts</td><td>10 disaster management and public health experts</td><td>Issues for palliative care in mass casualty event:<list list-type="simple" id="ulist0050"><list-item id="u0175"><label>•</label><p id="p0320">Role of palliative care with scarce resources</p></list-item><list-item id="u0180"><label>•</label><p id="p0325">Treatment decisions of those likely to die</p></list-item><list-item id="u0185"><label>•</label><p id="p0330">Knowing what palliative care services to provide, along with personnel and settings</p></list-item><list-item id="u0190"><label>•</label><p id="p0335">Ensuring training, supplies and organisational or jurisdictional arrangements</p></list-item></list>Authors recommended:<list list-type="simple" id="ulist0055"><list-item id="u0195"><label>•</label><p id="p0340">Training for non-palliative care professionals in management of symptoms and psychological support</p></list-item><list-item id="u0200"><label>•</label><p id="p0345">Plan for management of specific populations (elderly at home, those with learning disabilities)</p></list-item><list-item id="u0205"><label>•</label><p id="p0350">Planning for and ensuring ethical allocation of scarce resources</p></list-item><list-item id="u0210"><label>•</label><p id="p0355">Ensuring provision of palliative care at all medical care sites</p></list-item></list>Planning to provide palliative care during mass casualty events should be part of the current national and local disaster planning for training guidelines, protocols, and activities.</td></tr><tr><td>Cinti et al., 2008<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></td><td>United States, simulation exercise</td><td>To describe learning following simulation exercises for pandemic events</td><td>Simulation exercises with recommendations</td><td>A large tertiary care centre with 913 beds</td><td>An alternative care centre (ACC) was described as 4 pods accommodating a total of 250 patients, providing limited supportive care for non-critical pandemic influenza patients and some who would require palliative care.<break></break>Authors concluded that: (i) more attention was needed on palliative care and fatality management; (ii) plans should include involvement of clergy; (iii) palliative care protocols are essential, and there should be training for site leads in their use; and (iv) palliation medications should be included on the formulary.</td></tr><tr><td>Chen et al., 2006<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></td><td>Taiwan, Severe Acute Respiratory Syndrome (SARS)</td><td>To describe changes in hospice inpatient utilisation during and after the SARS epidemic in 2003 in Taiwan</td><td>Retrospective study using administrative data</td><td>Hospice wards within 15 hospitals</td><td>Changes in hospice inpatient utilisation during SARS epidemic:<break></break>During the peak SARS period, the number of admissions to the 15 hospice wards decreased to 69% of those in the previous year, and inpatient day units reduced to 54%. It was not known whether the decrease in utilisation was due to patients’ voluntary decisions, or hospital policies, and the study could not determine whether the needs of patients with terminal illnesses were met during the epidemic.<break></break>The authors concluded that the ability to shift resources from inpatient to community settings would improve care and that seamless continuity of care between facilities and settings should be ensured at all times.</td></tr><tr><td>Leong et al., 2004<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></td><td>Singapore, Severe Acute Respiratory Syndrome (SARS)</td><td>To describe the psychosocial impact of providing holistic care in an epidemic</td><td>Qualitative interviews</td><td>8 healthcare professionals (doctors, nurses, social workers and pharmacists) in a Palliative Care Unit</td><td>Psychosocial impact of providing holistic care in an epidemic:<list list-type="simple" id="ulist0060"><list-item id="u0215"><label>•</label><p id="p0360">Consequences of isolation</p></list-item><list-item id="u0220"><label>•</label><p id="p0365">Impact of uncertainty creating difficulties for patients, families and staff in preparing for death</p></list-item><list-item id="u0225"><label>•</label><p id="p0370">Impact for healthcare workers (risk of contracting disease, not being able to grieve)</p></list-item><list-item id="u0230"><label>•</label><p id="p0375">Disruption of bereavement for families (management of bodies after deaths)</p></list-item></list>Authors recommend that in an epidemic palliative care should include measures to improve connectedness, training in communication and bereavement counselling, and measures to help healthcare workers deal with stress.</td></tr></tbody></table></table-wrap></p><p id="p0090">The 10 articles were published between 2004 and 2020. Two papers concerned planning for pandemics,<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> seven papers described data collected during epi/pandemics,<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref>, <xref rid="bib8" ref-type="bibr">8</xref><sup>,</sup><xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> and one paper studied an epidemic retrospectively.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></p><p id="p0095">The settings included West Africa,<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> Taiwan,<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> Hong Kong,<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref> Singapore,<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> the United States,<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> and Italy.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref> One paper had no defined setting.<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> Eight of the papers concerned specific epi/pandemics (including Ebola,<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> SARS,<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref><sup>,</sup><xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> Influenza,<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> and one on COVID-19<sup>3</sup>).</p><p id="p0100">We synthesised findings according to Downar and Seccareccia model of systems, staff, space and stuff (<xref rid="tbl2" ref-type="table">Table 2</xref>).<table-wrap position="float" id="tbl2"><label>Table 2</label><caption><p>Synthesis of evidence and recommendations for the palliative care response to COVID-19</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>Systems</td><td><bold>Policies</bold><list list-type="simple" id="ulist0065"><list-item id="u0235"><label>•</label><p id="p0380">Require flexibility and rapid changes to systems and policies<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p></list-item><list-item id="u0240"><label>•</label><p id="p0385">Limiting visitor hours/ numbers<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p></list-item><list-item id="u0245"><label>•</label><p id="p0390">Change in admission criteria<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref></p></list-item><list-item id="u0250"><label>•</label><p id="p0395">Systems of daily telephone support for families<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref></p></list-item><list-item id="u0255"><label>•</label><p id="p0400">Stopping volunteer services<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p></list-item><list-item id="u0260"><label>•</label><p id="p0405">Palliative care and hospice care should be part of the national and local epi/pandemic planning<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></p></list-item></list><bold>Training and Protocols</bold><list list-type="simple" id="ulist0070"><list-item id="u0265"><label>•</label><p id="p0410">Palliative care protocols for non-specialist staff on management of symptoms and psychological support are essential<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref><sup>,</sup><xref rid="bib5" ref-type="bibr"><sup>5</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></p></list-item><list-item id="u0270"><label>•</label><p id="p0415">Training for site leads in the use of the protocols<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></p></list-item><list-item id="u0275"><label>•</label><p id="p0420">Education and training for non-specialist staff in basics of palliative care<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref>, including in communication and bereavement counselling<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p></list-item><list-item id="u0280"><label>•</label><p id="p0425">Consider separate guidelines for specific populations such as people in care homes and those with intellectual disabilities<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref></p></list-item></list><bold>Communication and coordination</bold><list list-type="simple" id="ulist0075"><list-item id="u0285"><label>•</label><p id="p0430">Sharing of protocols, advice and standards of care within organisations<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></p></list-item><list-item id="u0290"><label>•</label><p id="p0435">Identification of a decision maker to improve communication, particularly where multiple health professionals may be involved outside of their usual practice<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref></p></list-item><list-item id="u0295"><label>•</label><p id="p0440">Rapid triage to assess likelihood of response to treatment<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> and recognition of dying<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref></p></list-item></list><bold>Data</bold><list list-type="simple" id="ulist0080"><list-item id="u0300"><label>•</label><p id="p0445">Standardised information collection<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref></p></list-item><list-item id="u0305"><label>•</label><p id="p0450">Continuous monitoring and evaluation to inform operational changes or quality of services<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref></p></list-item></list></td></tr><tr><td>Staff</td><td><bold>Deployment of staff</bold><list list-type="simple" id="ulist0085"><list-item id="u0310"><label>•</label><p id="p0455">Flexibility of deployment, such as moving staff from acute setting to the community<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></p></list-item><list-item id="u0315"><label>•</label><p id="p0460">Sufficient staff numbers<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref></p></list-item><list-item id="u0320"><label>•</label><p id="p0465">Restricting contact with volunteers for infection control<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref>, while acknowledging volunteers are integral to the interdisciplinary model in palliative care and can make important contributions to psychosocial and bereavement care<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p></list-item></list><bold>Skill mix of staff</bold><list list-type="simple" id="ulist0090"><list-item id="u0325"><label>•</label><p id="p0470">Involving spiritual care and chaplains in the pandemic response<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></p></list-item><list-item id="u0330"><label>•</label><p id="p0475">Involving psychologists with expertise in palliative care<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref></p></list-item></list><bold>Ensuring resilience of staff</bold><list list-type="simple" id="ulist0095"><list-item id="u0335"><label>•</label><p id="p0480">Facilitating camaraderie among staff important to minimise negative psychosocial effects on staff, which include distress about risks of contracting the disease, grieving relatives or friends while working<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></p></list-item><list-item id="u0340"><label>•</label><p id="p0485">Measures to improve connectedness among staff<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p></list-item><list-item id="u0345"><label>•</label><p id="p0490">Training in communication and bereavement counselling<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p></list-item><list-item id="u0350"><label>•</label><p id="p0495">Measures to help healthcare workers deal with stress<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p></list-item></list></td></tr><tr><td>Space</td><td><bold>Moving to community provision</bold><list list-type="simple" id="ulist0100"><list-item id="u0355"><label>•</label><p id="p0500">Consider shifting resources from inpatient to community settings where demand may be higher<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></p></list-item><list-item id="u0360"><label>•</label><p id="p0505">Consider the setup of community care centres to expand outside hospital with standardised designs, include monitoring and evaluation instruments, and make use of training and supervision manuals. Community engagement to foster trust is important<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref></p></list-item></list><bold>Use of technology</bold><list list-type="simple" id="ulist0105"><list-item id="u0365"><label>•</label><p id="p0510">The role for virtual technology to enable communication, where visiting is restricted, for example providing a daily update for families<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p></list-item></list></td></tr><tr><td>Stuff</td><td><bold>Medicines and equipment</bold><list list-type="simple" id="ulist0110"><list-item id="u0370"><label>•</label><p id="p0515">Relevant symptom medications should be included in formularies<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref>, in the case of COVID-19 – breathlessness, cough, fever, delirium, anxiety, as well as pain</p></list-item><list-item id="u0375"><label>•</label><p id="p0520">Basic supplies of medications, intravenous catheters and lines<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></p></list-item><list-item id="u0380"><label>•</label><p id="p0525">Access to diagnostic and monitoring equipment<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref></p></list-item></list><bold>Personal protective equipment</bold><list list-type="simple" id="ulist0115"><list-item id="u0385"><label>•</label><p id="p0530">Sufficient supplies of PPE that are adaptable to the person<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></p></list-item></list></td></tr></tbody></table></table-wrap></p></sec><sec id="sec5"><title>Discussion</title><p id="p0105">We provide the first evidence synthesis to guide hospice and palliative care teams in their response to the COVID-19 pandemic. Key findings were the need for teams to be flexible and rapidly redeploy resources in the face of changing need. For hospital teams this involves putting in place protocols for symptom control and training non-specialists in their use. Hospice services may see a shift in need and should be prepared to focus their resources on community provision.</p><p id="p0110">This was a rapid review, and we did not assess quality of studies or grade our recommendations. We found existing evidence to be limited. All identified studies were observational, quantitative data were rare, and there were no studies with an experimental design. Most studies were from Asia or Africa, with one study from Europe and one from the United States. This reflects the fact that Europe and the United States are less experienced at responding to pandemics than other regions, and this may in turn result in a lack of preparedness to respond to COVID-19. While the importance of palliative care in response to pandemics has been well documented,<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref><sup>,</sup><xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> this is not reflected in pandemic plans or in palliative care training, and the research literature is sparse.</p><p id="p0115">There were gaps in evidence, particularly around the role of palliative care teams in acute hospitals. There was also relatively little data on provision of palliative care in community settings, though in two studies a reduction in demand for inpatient care was seen and led to the suggestion to shift resources into the community.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> Community palliative care can facilitate advance care planning and symptom control and helps prevent hospital admissions among people near the end of life.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref> It is likely that community palliative care may help prevent hospital admissions among people dying from COVID-19 who would prefer to remain at home or in their care home, though this has not been tested. However, the rapid escalation of breathlessness in patients with COVID-19 who develop acute respiratory distress syndrome (ARDS) may make this challenging.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> Severe breathlessness and respiratory disease are both known to be associated with increased hospital admissions at the end of life.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> Therefore, rapid community response may be needed to manage advanced disease in COVID-19 if people are to remain at home.</p><p id="p0120">Two studies reported cessation of hospice volunteer services in response to pandemics.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref> An alternative role for volunteers may be in provision of psychological support for patients and carers which could occur by using digital technology or telephones. In light of the social distancing measures being widely employed in response to COVID-19, volunteers may have a wider role in supporting communities for example helping the most vulnerable with shopping for food and medicines.</p><p id="p0125">Providing palliative care in pandemics can be compromised by the hostile environment, infection control mechanisms and extreme pressure on services.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref> In addition the family unit of care may be disrupted. Even so, provision of palliative care is an ethical imperative for those unlikely to survive, and may have the advantage of diverting dying people away from overburdened hospitals as well as providing the care that people want.<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> Pandemic situations introduce complex ethical challenges concerning allocation of scarce resources, and palliative care teams are well placed to help patients and carers discuss preferences and make advance care plans.</p><p id="p0130">Data collection systems to understand outcomes and share learning are important in a palliative pandemic response. However, these are frequently lacking.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> Such data should ideally include numbers of patients seen, as well as their main symptoms and concerns, treatments, effectiveness of treatment and outcomes. There is also a need to understand the prevalence of palliative care needs that are not met by palliative and hospice services. In a pandemic expected to last for several months such as COVID-19, implementing systems of data collection early would help services to plan for and improve care, and could be used to project future needs.</p></sec><sec id="sec6"><title>Conclusion</title><p id="p0135">Providing holistic care in a pandemic can be compromised by extreme pressure on services. Hospice and palliative care services can mitigate against this by 1) maintaining the ability to respond rapidly and flexibly; 2) ensuring protocols for symptom management and psychological support are available, and non-specialists are trained in their use; 3) being involved in triage; 4) considering shifting resources from inpatient to community settings; 5) considering redeploying volunteers to provide psychosocial and bereavement care; 6) facilitating camaraderie among staff and adopting measures to deal with stress; 7) use of technology to communicate with patients and carers; 8) adopting standardised data collection systems to inform operational changes and improve care. 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Survey</article-title><source>J Am Geriatr Soc</source><volume>64</volume><year>2016</year></element-citation></ref></ref-list><sec id="appsec1"><title>Appendix</title><sec id="appsec1.1"><title>Appendix A: Search Strategy</title><p id="p0155">There were no restrictions for language or publication date. Searches were completed 18<sup>th</sup> March 2020.</p></sec><sec id="appsec1.2"><title>MEDLINE and Embase</title><p id="p0160">(palliative care/ OR palliative medicine/ OR palliate$.mp. OR hospices/ OR terminally ill/ OR terminal care/ OR hospice$.mp. OR end of life.mp. OR EOL.mp.) AND (exp pandemics/ OR pandemic$.mp. OR epidemic$.mp. OR epidemics/ OR exp disease outbreaks/ OR disease outbreaks.mp. OR SARS.mp. OR SARS virus/ OR Severe Acute Respiratory Syndrome/ OR coronavirus/ OR coronavirus.mp. OR exp coronavirus infections/ OR ebolavirus/ OR influenza, human/ OR influenza.mp. OR hemorrhagic fever, ebola/ OR mers.mp. OR flu.mp. OR Middle East Respiratory Syndrome Coronavirus/ OR Tuberculosis/ OR Pulmonary tuberculosis/ OR Tuberculosis, multi-drug resistant/ OR Extensively drug resistant tuberculosis/ OR TB.mp.)</p></sec><sec id="appsec1.3"><title>PsycINFO</title><p id="p0165">(palliative care/ OR palliate$.mp. OR hospice/ OR terminally ill patient/ OR terminal care.mp. OR hospice$.mp. OR end of life.mp. OR EOL.mp.) AND (exp pandemics/ OR pandemic$.mp. OR epidemic$.mp. OR exp epidemics/ OR disease outbreaks.mp. OR SARS.mp. OR Severe Acute Respiratory Syndrome.mp. OR coronavirus.mp. OR influenza/ OR swine influenza OR ebola.mp. OR ebolavirus.mp. OR influenza.mp. OR mers.mp. OR flu.mp. OR Middle East Respiratory Syndrome Coronavirus.mp. OR Tuberculosis/ OR Pulmonary tuberculosis/ OR multi-drug resistant tuberculosis.mp. OR extensively drug resistant tuberculosis.mp. OR TB.mp.)</p></sec><sec id="appsec1.4"><title>CINAHL</title><p id="p0170">Searched for the below as title, abstract and keywords</p><p id="p0175">(Palliative care OR palliative medicine OR palliat* OR hospice* OR terminally ill OR terminal care OR end of life OR eol) AND pandemic* OR epidemic* OR disease outbreak OR SARS OR Severe acute respiratory syndrome OR SARS virus OR coronavirus OR coronavirus infections OR influenza OR flu OR MERS OR middle east respiratory syndrome OR ebola virus OR ebola OR Tuberculosis OR multidrug-resistant tuberculosis)</p></sec><sec id="appsec1.5"><title>Web of Science</title><p id="p0180">TS=(( palliative care OR palliative medicine OR palliat* OR hospice* OR terminally ill OR terminal care OR eol) AND (pandemic* OR epidemic* OR disease outbreak OR SARS OR Severe acute respiratory syndrome OR SARS virus OR coronavirus OR coronavirus infections OR influenza OR flu OR MERS OR middle east respiratory syndrome OR ebola virus OR ebola OR Tuberculosis OR multidrug-resistant tuberculosis))<table-wrap position="anchor" id="undtbl1"><table frame="hsides" rules="groups"><thead><tr><th>Section/topic</th><th>#</th><th>Checklist item</th><th>Reported on page #</th></tr></thead><tbody><tr><td colspan="3"><bold>TITLE</bold></td><td></td></tr><tr><td>Title</td><td>1</td><td>Identify the report as a systematic review, meta-analysis, or both.</td><td>1</td></tr><tr><td colspan="3"><bold>ABSTRACT</bold></td><td></td></tr><tr><td>Structured summary</td><td>2</td><td>Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.</td><td>2</td></tr><tr><td colspan="3"><bold>INTRODUCTION</bold></td><td></td></tr><tr><td>Rationale</td><td>3</td><td>Describe the rationale for the review in the context of what is already known.</td><td>3</td></tr><tr><td>Objectives</td><td>4</td><td>Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).</td><td>3</td></tr><tr><td colspan="3"><bold>METHODS</bold></td><td></td></tr><tr><td>Protocol and registration</td><td>5</td><td>Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.</td><td>N/A</td></tr><tr><td>Eligibility criteria</td><td>6</td><td>Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.</td><td>3</td></tr><tr><td>Information sources</td><td>7</td><td>Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.</td><td>3/4</td></tr><tr><td>Search</td><td>8</td><td>Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.</td><td>Appendix A</td></tr><tr><td>Study selection</td><td>9</td><td>State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).</td><td>4</td></tr><tr><td>Data collection process</td><td>10</td><td>Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.</td><td>4</td></tr><tr><td>Data items</td><td>11</td><td>List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.</td><td>N/A</td></tr><tr><td>Risk of bias in individual studies</td><td>12</td><td>Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.</td><td>N/A</td></tr><tr><td>Summary measures</td><td>13</td><td>State the principal summary measures (e.g., risk ratio, difference in means).</td><td>N/A</td></tr><tr><td>Synthesis of results</td><td>14</td><td>Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref>) for each meta-analysis.</td><td>4</td></tr></tbody></table><table frame="hsides" rules="groups"><thead><tr><th>Section/topic</th><th>#</th><th>Checklist item</th><th>Reported on page #</th></tr></thead><tbody><tr><td>Risk of bias across studies</td><td>15</td><td>Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).</td><td>N/A</td></tr><tr><td>Additional analyses</td><td>16</td><td>Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.</td><td>N/A</td></tr><tr><td colspan="3"><bold>RESULTS</bold></td><td></td></tr><tr><td>Study selection</td><td>17</td><td>Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.</td><td>24</td></tr><tr><td>Study characteristics</td><td>18</td><td>For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.</td><td>7-15</td></tr><tr><td>Risk of bias within studies</td><td>19</td><td>Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).</td><td>N/A</td></tr><tr><td>Results of individual studies</td><td>20</td><td>For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.</td><td>7-15</td></tr><tr><td>Synthesis of results</td><td>21</td><td>Present results of each meta-analysis done, including confidence intervals and measures of consistency.</td><td>N/A</td></tr><tr><td>Risk of bias across studies</td><td>22</td><td>Present results of any assessment of risk of bias across studies (see Item 15).</td><td>N/A</td></tr><tr><td>Additional analysis</td><td>23</td><td>Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).</td><td>N/A</td></tr><tr><td colspan="3"><bold>DISCUSSION</bold></td><td></td></tr><tr><td>Summary of evidence</td><td>24</td><td>Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).</td><td>20-22</td></tr><tr><td>Limitations</td><td>25</td><td>Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).</td><td>20</td></tr><tr><td>Conclusions</td><td>26</td><td>Provide a general interpretation of the results in the context of other evidence, and implications for future research.</td><td>22</td></tr><tr><td colspan="3"><bold>FUNDING</bold></td><td></td></tr><tr><td>Funding</td><td>27</td><td>Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.</td><td>22-23</td></tr></tbody></table><table-wrap-foot><fn id="tspara0010"><p><italic>From:</italic> Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. <ext-link ext-link-type="doi" xlink:href="10.1371/journal.pmed1000097" id="intref0010">https://doi.org/10.1371/journal.pmed1000097</ext-link></p></fn><fn id="tspara0015"><p>For more information, visit: <ext-link ext-link-type="uri" xlink:href="http://www.prisma-statement.org" id="intref0015"><bold>www.prisma-statement.org</bold></ext-link>.</p></fn></table-wrap-foot></table-wrap></p></sec></sec><ack id="ack0010"><title>Disclosures and Acknowledgements</title><p>The authors have no conflicts of interest to declare.</p><p>Funding</p><p>This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. KES is funded by a National Institute of Health Research (NIHR) Clinician Scientist Fellowship (CS-2015-15-005), IJH is an NIHR Senior Investigator Emeritus. IJH is supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. IJH leads the Palliative and End of Life Care theme of the NIHR ARC South London, and co-leads the national theme in this. RLC is funded by Marie Curie and Cicely Saunders International; AEB by Cicely Saunders International and the Dunhill Medical Trust. SNE, NL and AEB are previous Cicely Saunders International PhD training fellows. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the funding charities.</p></ack><fn-group><fn id="d32e1087"><p id="ntpara0010">Contributions</p></fn><fn id="d32e1090"><p id="ntpara0015">KES conceived the idea for the study and wrote the protocol with input from IJH. SNE planned and carried out the searches. RC, SNE, NL and KES screened articles. KES and NL extracted data. KES wrote the manuscript with significant input from AEB, SNE and IJH. All authors critically reviewed and agreed the final manuscript.</p></fn></fn-group></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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