Palliative Medicine

Rising need for palliative and end-of-life care requires reliable cost-effectiveness evidence to support optimal resource allocation. Relevant value propositions and the applicability of conventional economic evaluation methods, however, may differ from other healthcare fields.

To synthesise and critically appraise context-specific economic evaluations with comprehensive methodological and quality lenses including decision-making aspects.

We conducted a systematic review of published palliative and end-of-life economic evaluations following a registered, peer-reviewed protocol (CRD42020148160). Cost-effectiveness results, methods, reporting quality (CHEERS), study quality (CHEC) and decision-making contexts were summarised narratively.

The databases EMBASE, HTA-Database, MEDLINE, and NHS-EE-Database were searched between 2010 and 2024.

Of the 4190 identified references, 46 studies were included. Overall, 59% of the studies stemmed from four countries (UK, Canada, the Netherlands, USA), 54% were trial-based economic evaluations, 59% investigated cancer-related interventions, 41% were conducted in hospital settings, 63% were cost-utility analyses with 83% using EQ-5D for QALY-calculations. Studies typically took a health (and social) care perspective (63%) with 58% corresponding to national health technology assessment decision-making requirements. Of the evaluated interventions, 51% were cost-effective. Reporting quality (52%–96%) and study quality (56%–94%) greatly varied.

Economic evaluations in palliative and end-of-life care settings mainly adhered to commonly required decision-making frameworks. This may result in sub-optimal analytical perspectives leading to important missed consequences, omitted alternative value considerations, and ignorance of some existing context-specific methodological recommendations. Developing and promoting consensus-based, context-specific methodological recommendations would be crucial to enhance the appropriateness of economic evaluation evidence in this context.

High-quality evidence suggests that specialist palliative care reduces the odds of dying in hospital. The economic implications have not been established.

To evaluate the cost-effectiveness of home- and hospital-based specialist palliative care for adults with poor prognosis in England.

Health-economic decision-modelling using five-state Markov cohort models with a 24-h cycle and lifetime horizon.

We evaluated home- and hospital-based care separately. We modelled counterfactuals using Cochrane review evidence of treatment effects on place of death and quality of life. We estimated place of death distributions, utilisation, quality-adjusted life years, and unit and intervention costs from the literature.

Home-based care was associated with reduced costs of £7908 per person (95% confidence interval: −18,044 to 395) and increased quality-adjusted life years by 0.035 per person (0.033 to 0.037). Hospital-based care reduced costs by £6480 per person (−11,482 to −1671) and increased quality-adjusted life years by 0.033 per person (0.031 to 0.035). We estimated that for England in 2022, specialist palliative care supported over 20,000 people to die outside of hospital, saved approximately 1.5 million hospital bed days and reduced system expenditures by £817 million.

Specialist palliative care reduces hospital bed days, deaths in hospital and healthcare costs, as well as improving quality of life, among adults in England. A minority who might benefit currently receive specialist palliative care and needs are growing rapidly. Expanding access may yield further gains, but bridging current gaps in access also requires new approaches to reaching and meeting the needs of underserved groups.

Although telehealth is increasingly implemented in palliative oncology, the psychosocial effectiveness of nurse-led telehealth interventions remains unclear. Existing reviews are largely descriptive and do not isolate nurse-delivered interventions or synthesize psychosocial outcomes for both patients and family caregivers.

To evaluate the effectiveness of nurse-led telehealth interventions on psychosocial outcomes among patients with cancer receiving palliative care and their family caregivers.

Systematic review and meta-analysis.

Nine electronic databases were searched from inception to April 2025 for randomized controlled trials evaluating nurse-led telehealth interventions.

Nine trials (n = 3177 participants) were included. Among patients, nurse-led telehealth significantly reduced anxiety (Hedges’ g = 0.46) and improved quality of life (Hedges’ g = 0.33). Effects on depressive symptoms were not statistically significant. Among family caregivers, significant improvements were observed in anxiety (Hedges’ g = 0.30), depression (Hedges’ g = 0.42), quality of life (Hedges’ g = 0.45), and stress burden (Hedges’ g = 0.44). Interventions comprising more than six sessions demonstrated greater effectiveness for selected outcomes.

Nurse-led telehealth interventions improve psychosocial outcomes in palliative oncology for both patients and family caregivers. Structured and adequately intensive programs may enhance intervention impact and support evidence-based digital nursing practice.

Dry mouth is a disruptive symptom in patients with life-limiting illnesses. It has one of the highest symptom burdens in palliative care and a significant impact on quality of life. Nonetheless, dry mouth remains an underacknowledged and undertreated symptom with limited evidence-based interventions.

To examine the quality and content of guidelines for the treatment of dry mouth in patients with life-limiting illnesses.

A systematic review of clinical practice guidelines was conducted (preregistered in PROSPERO in 2023). PRISMA reporting guidelines were followed. The search strategy involved 4 scientific databases and 9 guideline databases, targeted searches and stakeholder outreach for 183 countries/regions. Quality and content were analysed using the AGREE II instrument and directed content analysis, respectively.

Seventy-two clinical practice guidelines from 42 countries across 6 continents were included.

Only two guidelines were recommended for use based on the AGREE II quality appraisal. Four main themes emerged from the content analysis: (1) Assessment of dry mouth by medical history, oral examination and measuring instruments (n = 32, n = 36 and n = 19 guidelines respectively); (2) Oral care (n = 68); (3) Management by treating causes (n = 40), saliva substitutes (n = 66) and stimulants (n = 62), diet (n = 45), and medication (n = 40); and (4) Patient and family involvement (n = 43).

Despite differences in quality and comprehensiveness of guidelines for treatment of dry mouth in palliative care, many care practices are shared worldwide. This review highlights the need for methodologically robust guidelines with a strong evidence base that specifically focus on dry mouth.

Reiki and Therapeutic Touch are complementary therapies sometimes used in palliative and end-of-life care.

To examine the available evidence regarding the effects of Reiki and Therapeutic Touch, compared to usual care, in palliative and end-of-life care.

Systematic review registered in PROSPERO (CRD420251059364; May 23, 2025).

MEDLINE, Web of Science, and Scopus were searched for English-language studies published between 2013 and 2024. Eligible studies included patients receiving palliative care who underwent Reiki and/or Therapeutic Touch compared with usual care. Any primary study design was eligible. Risk of bias was assessed and findings synthesized narratively.

Nine studies involving 415 participants were included: five mixed-methods studies, three randomized controlled trials, and one qualitative cross-sectional study conducted in North America (n = 6) and Europe (n = 3). Cancer was the predominant diagnosis. Risk of bias raised some concerns in randomized trials and was moderate to high in qualitative and non-randomized designs. Some studies reported improvements in symptoms (pain, anxiety, depression, fatigue, and stress), and in quality-of-life domains (sleep, relaxation, energy, hope, and emotional well-being). Qualitative findings described perceived relaxation, comfort, and emotional support. Reporting of harms was limited; only one study monitored adverse events and reported one serious event considered potentially related to the intervention.

Evidence regarding Reiki and Therapeutic Touch in palliative and end-of-life care remains limited and heterogeneous. The very low certainty of evidence precludes firm conclusions regarding their effectiveness. Further well-designed studies are needed to clarify their potential role in palliative care.

Dignity is a cornerstone of palliative care and represents a complex, multidimensional concept that warrants further conceptual integration.

To synthesise evidence regarding patients’ experiences of dignity in palliative care, with a particular emphasis on cultural influenceVs.

An integrative review was conducted following Whittemore and Knafl’s framework.

Six databases (CINAHL, MEDLINE, ProQuest Sociological Abstracts, PsycINFO, Scopus, and Web of Science) were searched from inception to 28 February 2025. Targeted hand-searches of key journals were performed between March and June 2025.

A total of 32 articles were included. Patients’ understandings varied but dignity was commonly described as “being treated like a human being.” Three themes were identified: (1) Inner experience, encompassing physical and psychological experiences, self-worth, resilience, and spirituality; (2) Relational and interactional dynamics, including personal autonomy and self-determination, and social relationships and support systems; and (3) Macro-structural determinants, comprising healthcare systems and delivery, as well as economic and socio-political circumstances. Cultural values shaped the perception and preservation of dignity. In collectivist societies, dignity was intricately linked to family, community, religion, and social harmony, whereas in individualist societies, dignity centred on autonomy and control over end-of-life decisions. Immigrants negotiated dignity through interactions between cultural values and healthcare expectations within host countries.

This review provides an integrated understanding of the factors shaping patients’ perceptions of dignity in palliative care across cultures. The findings could usefully inform patient-centred and culturally sensitive palliative care practices that uphold dignity and promote well-being at the end of life.

Telemedicine may improve access and delivery of palliative care in low and middle-income countries (LMICs). Despite increasing adoption and diverse applications, there is limited understanding of their use in palliative care.

Determine the challenges, enablers and key characteristics of telemedicine interventions targeting outcomes delivered in palliative care in LMICs.

A scoping review guided by the JBI methodology.

Six databases (MEDLINE, EMBASE, PsycInfo, Global Health, CINAHL and IEEE Xplore) were searched for reports published between 2003 and August 2025. WHO IRIS and clinical trial registries were searched in March 2026. Forward and backward citation searching was also conducted.

Of the 7938 reports identified from database searches, 21 met the inclusion criteria. Additional searches of WHO IRIS and clinical trial registries did not identify any additional reports. Most interventions focused on telemonitoring (n = 14), commonly delivered via telephone (n = 8) and involving a doctor/clinician (n = 8). Four studies measured only objective levels of engagement, one study assessed only subjective engagement, while three studies measured both objective and subjective engagement, but the measures used across these studies were heterogeneous. Three studies identified challenges to engaging with telemedicine interventions, including poor digital literacy, lack of a physical exam, and poor internet connectivity.

Telemedicine demonstrates emerging, context-specific potential to support access to palliative care in LMICs, although the current evidence base is limited and concentrated in middle-income and cancer-focused settings. Future research should adopt theoretically informed, system-integrated approaches with consistent evaluation to ensure equitable and sustainable delivery.

While forgiveness is linked to emotional and physical benefits at the end of life, little is known about how it is understood or addressed by palliative care professionals. Spiritual caregivers, especially in the Netherlands where formal training is growing, may be well-placed to support such conversations, yet their experiences remain underexplored.

To explore how Dutch spiritual caregivers perceive and engage with forgiveness at the end of life, including their potential role in facilitating it.

This qualitative study used interpretative phenomenological analysis. In-person, semi-structured interviews were analyzed through reflexive thematic analysis.

Eleven interviews were conducted with spiritual caregivers from various hospitals across the Netherlands. Interviews took place in hospitals (n = 6), caregivers’ homes (n = 2), via Zoom (n = 2), and by phone (n = 1). Due to conceptual differences related to religious and existential backgrounds, nine interviews were finally selected, focusing on the Christian (Catholic n = 4, Protestant n = 4) and non-affiliated (n = 1) ones.

Four main themes emerged: (1) concept of forgiveness according to spiritual caregivers; (2) forgiveness as a theme in the conversation between spiritual caregivers and patients, (3) barriers to talking about forgiveness, and (4) the role of spiritual caregivers in addressing forgiveness.

Spiritual caregivers acknowledged forgiveness as beneficial but noted challenges—logistical, cultural, and personal—that make direct conversations difficult. As a result, they often adopt a subtle, indirect approach, using rituals and attentive listening to address forgiveness with patients nearing the end of life.

The Attentive Visitors training was developed to increase community volunteers’ knowledge, skills and confidence regarding their role, signposting, and communication to address palliative care needs with community residents and healthcare professionals.

To pilot-test and evaluate the effectiveness and acceptability of the training at the volunteer level.

Multi-method design utilizing a quantitative pre-test/post-test survey before (T0), immediately after (T1) and 2 months after (T2) the training to assess effectiveness; focus groups and interviews to evaluate subjective effectiveness and acceptability; and the Most Significant Change Technique to capture the wider impact of the training.

Participants included community volunteers and stakeholders involved in palliative home care, primary care, and volunteer coordination in Flanders, Belgium. They were purposively sampled through Samana, a nonprofit organization supporting people with chronic illness and their informal caregivers.

The training was pilot-tested among 59 community volunteers across six locations in Flanders, Belgium. Thirty-seven (63%) volunteers completed both modules (i.e. the didactic and follow-up session). Nineteen volunteers participated in interviews and eight stakeholders took part in a group discussion. The training had a positive effect (at T2) on knowledge about palliative care (0.58 fewer incorrect answers at T2; p = 0.011) and self-efficacy in discussing identified needs with a community resident (+0.51 at T2; p < 0001) and healthcare professional (+0.42 at T2; p = 0022). Community volunteers reported increased awareness of their own importance, more self-efficacy in setting boundaries, and more self-confidence in communicating with community residents and healthcare professionals. Community volunteers indicated that the training met their expectations, was useful, and that benefits were proportionate to required efforts.

The training was evaluated positively on effectiveness and acceptability, enabling volunteers to respond better to palliative care needs and to support them in their signposting role. Findings of this early evaluation, focusing on short-term outcomes, suggest that this training program can be scaled up and integrated into educational programs of stakeholder organizations.

Injectable anticipatory medications are routinely prescribed ahead of need in many countries to help manage distressing end-of-life symptoms. However, little is known about the lived experience of patients and informal caregivers as they navigate their prescription, supply and use.

To explore and map patient journeys in navigating anticipatory medication care, and to identify healthcare interactions with the greatest potential for enhancing patient and informal caregiver experiences of care.

Qualitative secondary analysis of longitudinal interview data using framework analysis and patient journey mapping techniques.

Adults (18+) prescribed anticipatory medications (n = 6), informal caregivers (n = 9) and health care professionals involved in their care (n = 5).

Visually mapping journeys highlighted that patients and informal caregivers’ experiences of anticipatory medication processes varied greatly and were influenced by the context of care. All participants appreciated access to injectable medications for future symptom control. However, journeys repeatedly highlighted suboptimal information exchange between patients, informal caregivers and healthcare professionals, regarding their purpose and threshold for use. Navigating unfamiliar and complex end-of-life medication support systems was more challenging when patients lived alone or experienced communication difficulties.

Patient and informal caregiver experiences of timely symptom control could be improved by healthcare professionals having open and ongoing conversations about the role of anticipatory medications. Simplified and well-signposted routes for accessing healthcare professional advice and medication input are needed. Using journey mapping offers a novel way to visually illustrate different patient and informal caregivers lived experience and can be adapted for researching experiences of various care pathways.

While the adoption of psilocybin-assisted therapy for existential distress offers promising support for patients with life-threatening illnesses, implementing this intervention into palliative care settings presents significant real-world challenges.

To examine palliative care stakeholders’ knowledge and attitudes regarding psilocybin-assisted therapy, and identify barriers and facilitators to its implementation.

We conducted a cross-sectional online survey between April 15 and December 18, 2024. The survey assessed perceived knowledge, attitudes, and perceived barriers and facilitators to the effective integration of psilocybin-assisted therapy into palliative care settings.

One hundred and twenty-one adults involved in palliative care (physicians, other healthcare professionals, caregivers, and managers) were recruited from Canada’s four most populous provinces: Québec, Ontario, Alberta, and British Columbia.

Forty-three percent of stakeholders reported having good knowledge of psilocybin’s potential benefits and risks. Attitudes towards psilocybin-assisted therapy were predominantly non-favourable (61%), yet varied across occupational groups (p < 0.0001), with 95% of physicians reporting favourable attitudes. The lack of trained healthcare providers was viewed as the primary barrier to implementation. Key facilitators included further research and developing standardised intervention protocols. Sixty-eight percent of stakeholders endorsed the introduction of psilocybin-assisted therapy during the early stages of the illness trajectory.

Translating the potential of psilocybin-assisted therapy for existential distress from clinical trials into palliative care settings requires careful consideration and collaboration with stakeholders. Given the significant divergence in perspectives between clinical and non-clinical groups, tailored interprofessional education could help build shared understanding and support effective implementation. Being conducted in Canada, transferability to different regulatory frameworks may be limited.

Mistletoe extract is a widespread complementary therapy mainly used for quality-of-life improvement in cancer patients. Advanced pancreatic cancer is associated with poor quality of life and better therapies for symptomatic relief are highly needed.

MISTRAL aimed to assess the impact of mistletoe extract on quality of life, body weight, observed costs and blood biomarkers in patients with advanced pancreatic cancer.

MISTRAL was an investigator-initiated, phase III, randomized, double-blind, placebo-controlled, parallel-group, superiority, multicenter, clinical trial with a nested biomarker study. Registration EudraCT 2014–004552–64, NCT02948309.

At 9 oncology centers, 290 participants were randomized to standard treatment (palliative chemotherapy or best supportive care) plus subcutaneous mistletoe extract or placebo. Main inclusion criteria were advanced pancreatic cancer, performance status 0–2, main exclusion criteria neuroendocrine pancreatic tumor. EORTC-QLQ-C30, EORTC-QLQ-PAN26, body weight, cost parameters and biomarkers were assessed from baseline up until 9 months.

No statistically significant differences for quality of life and weight were evident between treatment arms. Parameters for observed costs for supportive and inpatient care (days at hospital, parenteral nutrition infusions, nutritional supplement drinks, number of visits of palliative home care teams, symptom-relieving medication) were similar in both arms. Thus, calculation of costs was not performed. No effect on explored biomarkers (differential blood count, lymphocyte subpopulations, C-reactive protein, albumin and Ca19-9) was found except for a statistically significant increase of eosinophils in the mistletoe arm without association to clinical effect.

Since no benefit was observed, there is no clinical reason to recommend mistletoe extract in patients with advanced pancreatic cancer.