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1、Review ArticleComplementary and Alternative Medicine in Hospiceand Palliative Care:A Systematic ReviewYvette S.Zeng,PharmD,Connie Wang,PharmD Candidate,Kristina E.Ward,PharmD,andAnne L.Hume,PharmDUniversity of Rhode Island,Kingston,Rhode Island,USAAbstractContext.The aim of palliative care is to imp
2、rove quality of life for patients with serious illnesses by treating their symptomsand adverse effects.Hospice care also aims for this for patients with a life expectancy of six months or less.When conventionaltherapies do not provide adequate symptom management or produce their own adverse effects,
3、patients,families,andcaregivers may prefer complementary or alternative approaches in their care.Objectives.The objectives of this study were to evaluate the available evidence on the use of complementary or alternativemedicine(CAM)in hospice and palliative care and to summarize their potential bene
4、fits.Methods.A defined search strategy was used in reviewing literature from major databases.Searches were conducted usingbase terms and the symptom in question.Symptoms included anxiety,pain,dyspnea,cough,fatigue,insomnia,nausea,andvomiting.Studies were selected for further evaluation based on rele
5、vancy and study type.References of systematic reviews werealso assessed.After evaluation using quality assessment tools,findings were summarized and the review was structured basedon Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Results.Out of 4682 studies,17 were ide
6、ntified for further evaluation.Therapies included acupressure,acupuncture,aromatherapy massage,breathing,hypnotherapy,massage,meditation,music therapy,reflexology,and reiki.Many studiesdemonstrated a short-term benefit in symptom improvement from baseline with CAM,although a significant benefit was
7、notfound between groups.Conclusion.CAM may provide a limited short-term benefit in patients with symptom burden.Additional studies areneeded to clarify the potential value of CAM in the hospice or palliative setting.J Pain Symptom Manage 2018;56:781e794.?2018 American Academy of Hospice and Palliati
8、ve Medicine.Published by Elsevier Inc.All rights reserved.Key WordsComplementary therapy,alternative therapy,palliative care,hospice care,symptom management,reviewIntroductionAbout one-third of American adults have reporteduseofcomplementaryandalternativemedicine(CAM)including mind and body practice
9、s,amongmany others.1,2Despite increasing use,many CAMtherapies lack sufficient,high-quality evidence to sup-port their use in the prevention and treatment ofdiverse conditions.3In addition,many health care pro-fessionals continue to have inadequate knowledgeabout CAM therapies.CAM therapies have bee
10、n used in the palliative careand hospice settings for many years,especially in theU.K.Patients in these settings commonly report ahigh symptom burden potentially affecting their qual-ity of life.Distressing symptoms may be related both tothe underlying disease and adverse effects from treat-ment.As
11、a result,when conventional therapies do notprovide adequate symptom relief or produce addi-tional adverse effects,patients,families,and caregiversmay select CAM approaches,especially near the end oflife.Data from the 2007 National Home and HospiceCare Survey revealed that CAM was offered by over40%o
12、f hospice care providers.About one-quarter ofAddress correspondence to:Anne L.Hume,College of Phar-macy,University of Rhode Island,7 Greenhouse Road,King-ston,RI 02881,USA.E-mail:alhumeuri.eduAccepted for publication:July 23,2018.?2018 American Academy of Hospice and Palliative Medicine.Published by
13、 Elsevier Inc.All rights reserved.0885-3924/$-see front matterhttps:/doi.org/10.1016/j.jpainsymman.2018.07.016Vol.56 No.5 November 2018Journal of Pain and Symptom Management781the surveyed patients received some form of a CAMtherapy during hospice care.The therapies mostcommonly offered by hospice c
14、are providers includedmassage,supportive group therapy,and music ther-apy.4The Hospice and Palliative Nurses Associationhas also recognized the prevalence and potentialrole of CAM in the palliative and hospice setting.The Hospice and Palliative Nurses Association encour-ages the use of licensed and/
15、or certified CAM servicesto provide holistic end-of-life care.5With increasing support for CAM,the need formore data on different practices has continued togrow.A 2000 systematic review assessed the effective-ness of CAM therapies on selected symptoms at endof life.The authors identified that acupun
16、cture andmassage,among others,may provide pain relief whilepatients with end-stage chronic obstructive lung dis-ease may have less dyspnea from using acupressureand muscle relaxation.6In the almost 20 years inter-vening,additional studies assessing the potential roleof CAM therapies at the end of li
17、fe have been pub-lished.The purpose of this systematic review was toidentify and evaluate new evidence of CAM therapiesin managing common symptoms and improving qual-ity of life in the palliative and hospice setting.MethodsProtocol and RegistrationThe systematic review was conducted in accordanceto
18、the Preferred Reporting Items for Systematic Re-views and Meta-Analyses statement and is registeredin the International Prospective Register of SystematicReview:CRD42017067375.7,8Literature SearchA literature search was conducted in four databasesincluding MEDLINE through PubMed,CumulativeIndex to N
19、ursing and Allied Health Literature(CI-NAHL),PsycINFO,and Embase,for studies that as-sessed the efficacy of a CAM therapy in a palliativeor hospice setting.The initial search was focused onthe common symptoms that patients would experi-ence in this setting.Specific terms were used according to the d
20、atabasespreferred terminology.Medical subject heading terms,headings,thesaurus terms,and Emtree terms wereused for PubMed,CINAHL,PsycINFO,and Embase,respectively.The search consisted of three base terms,complementary medicine,palliative care,hos-pice care,and a specific symptom as a fourth term.Comp
21、lementary was the preferred medical subjectheadingterminPubMedwhilealternativewas preferred for Embase,PsycINFO,and CINAHL.Symptoms included pain,nausea,vomiting,anxiety,cough,fatigue,insomnia,and dys-pnea.Allarecommonlyreportedbypatientsreceiving palliative care,with the majority of patientsdiagnos
22、ed with cancer.6,9Filters for study types,daterange of January 1999 to May 2016,and English lan-guage were applied after entering search terms to nar-row results.A second search focused on CAM and quality of lifeat end of life was also conducted to include multiplesymptoms and overall aspects of a p
23、atients life.Inthis search,the same initial base terms,complemen-tary medicine,palliative care,hospice care,wereused and the fourth term was quality of life.Table 1provides an overview of the specific terms used and fil-ters applied according to database.A third search was conducted using the same s
24、earchterms and filters for date range and English language.However,rather than filter for controlled trials,a filterfor systematic reviews was applied.EligibilityEach author screened results from one assigneddatabase based on title and abstract.To be eligiblefor review,controlled trials had to asses
25、s the efficacyof a CAM therapy in managing a symptom or qualityof life in patients in a palliative or hospice setting.Sys-tematic reviews were screened using the same eligi-bilitycriteria.Oncesystematicreviewswereidentified,their references were screened for addi-tional controlled trials and systema
26、tic reviews thatmet the inclusion criteria.References of these addi-tional sources were also screened.Meeting abstractsand quasi-experimental studies were excluded and du-plicates were also removed.Study Selection,Data Extraction,and AnalysisAfter compiling the full-text articles,all authorsindepend
27、ently assessed and scored them using the Ja-dad scale for controlled trials.Randomization,blind-ing,and accountability for study participants are allfactors assessed in the Jadad scale and account for se-lection bias,performance and detection bias,andattrition bias,respectively.10Studies that receiv
28、ed a Ja-dad score of 3 or greater were included.A meeting of the four authors was held to review Ja-dad scores.Disagreements were resolved by discussionof the studies,and a consensus was subsequentlyreached.After finalizing selected articles,each authorindependently extracted the data that were subs
29、e-quently verified by the other three authors.The studydesign,patient population,CAM intervention,dura-tion of therapy,symptom(s)assessed,outcomes,mea-surement tools,and results were assessed.Ofthe3705uniquerecordsidentifiedandscreened,86 full-text articles were analyzed in depth.Of these,69 were ex
30、cluded for reasons such as782Vol.56 No.5 November 2018Zeng et al.Table 1Summary of Search Strategies and Number of ResultsDatabaseSearch TermsSymptoms Quality of LifeApplied FiltersNo.of ResultsaMEDLINE(PubMed)(Complementary TherapiesMesh)AND(Hospiceand Palliative Care NursingMesh OR PalliativeCareM
31、esh OR Palliative MedicineMesh ORHospice CareMesh)AND SYMPTOMMesh)PainMeshDyspneaMeshCoughMeshNauseaMeshVomitingMeshAnxietyMeshSleep Initiation and Maintenance DisordersMeshFatigueMeshStudy types:Clinical study/trialControlled clinical trialRandomized controlled trialSystematic reviewsMeta-analysisM
32、ulticenter studyObservational studyDate:1999e2016140CINAHL(MH Alternative Therapies)AND(MH PalliativeCare)OR(MH Hospice and Palliative Nursing)OR(MH Terminal Care)OR(MH Hospice Care)AND(MH SYMPTOM)(MH Pain)(MH Dyspnea)(MH Nausea)(MH Nausea and Vomiting)(MH Vomiting)(MH Anxiety)(MH Insomnia)(MH Fatig
33、ue)Study types:Clinical trialMeta-analysisRandomized controlled trialResearchSystematic reviewDate:January 1999 to May 2016197Embasealternative medicine/exp AND palliative therapy/expOR palliative nursing/exp AND SYMPTOM/exppain/expdyspnea/expcoughing/exp NOT pertussis NOT experimentalcoughingnausea
34、/expvomiting/exp NOT experimental emesisanticipatory nausea and vomiting/expchemotherapy induced emesis/expchemotherapy induced nausea and vomiting/expradiation induced emesis/expnausea and vomiting/mjanxiety/expinsomnia/expfatigue/exp NOT persian gulf syndrome NOT postviralfatigue syndromeStudy typ
35、es:Clinical trialProspective studyRandomized controlled trialSystematic reviewRetrospective studyDate:1999e2016458PsycINFOSU.EXACT.EXPLODE(Alternative Medicine)ANDSU.EXACT.EXPLODE(Palliative Care)ORSU.EXACT.EXPLODE(Hospice)ANDSU.EXACT.EXPLODE(SYMPTOM)SU.EXACT.EXPLODE(Pain)SU.EXACT.EXPLODE(Dyspnea)SU
36、.EXACT.EXPLODE(Nausea)SU.EXACT.EXPLODE(Vomiting)SU.EXACT.EXPLODE(Anxiety)SU.EXACT.EXPLODE(Insomnia)SU.EXACT.EXPLODE(Fatigue)Methodology:Follow-up studyMeta-analysisProspective studySystematic reviewTreatment outcome/clinical trialDate:After December 31,1998 to May 2016695This chart demonstrates the
37、search strategy used,including search terms and filters used for each database and the number of results produced.Included terms are specific to their respective database.A separate searchwas conducted for each symptom listed.Not all databases included a symptom of interest(i.e.,cough was not a vali
38、d search term in CINAHL).aWith duplicates removed.Vol.56 No.5 November 2018783CAM in Hospice and Palliative Careinappropriatestudypopulation,resultingin17eligible for inclusion(Fig.1).ResultsTable 2 summarizes findings from the 17 includedstudies of CAM interventions in the palliative or hos-pice ca
39、re setting.The studies that met our inclusioncriteria assessed mind and body interventions.Symp-toms assessed included pain,nausea and vomiting,dyspnea,anxiety and depression,and quality of life.Many studies tested for improvement in multiplesymptoms,withpainmostfrequentlyassessed(n 8).Sixteen trial
40、s enrolled patients with advancedcancer with a few including patients with other dis-eases and one enrolling patients with HIV/AIDS.The Visual Analogue Scale(VAS)and RotterdamSymptom Checklist(RSCL)were the most commonlyusedmeasurementtools.Assessmenttoolsaredescribed in Supplemental Table 1.Acupres
41、sureOne study assessed the efficacy of acupressureversus sham wristbands in reducing nausea and vomit-ing for three days.11Measurements were recordedevery six hours while wearing the wristbands.One pa-tient reported mild swelling as an adverse event.Anti-emetics were continued for participants,altho
42、ugh thespecific drug and administration time were not docu-mented.The study was a pilot study,and evidence ofa difference between study groups was unlikely.Theinvestigatorssuggestedthatacupressuremaybeconsidered as an adjunct for palliative care patientsin controlling nausea and vomiting.Acupuncture
43、A pilot study evaluated the efficacy of electroacu-puncture versus a palliative care nurseeled supportivecare group for multiple symptoms based on the Ed-montonSymptomAssessmentScale(ESAS).12Acupuncture points were chosen based on specificsymptoms of each patient.The supportive groupinvolved a 20-to
44、 30-minute meeting with a palliativecare nurse who provided counseling,emotional sup-port,and coping strategies.Scores were recordedbefore and immediately after each intervention,andduringweeklyfollow-ups.Acupunctureimprovedsymptoms immediately after each session,yet ESASscores increased by the six-
45、week follow-up.Right-legstiffness and a falling asleep sensation were theonly reported adverse effects.Nurse-led supportiveRecords identified through database search(n=1837)Records identified through systematic review references(n=2845)Records after duplicates removed(n=3705)Records screened(n=86)Re
46、cords excluded(Titles and abstracts not meeting inclusion criteria upon initial screening)(n=3619)Full-text articles assessed for eligibility(n=86)Articles excluded,with reasons(n=69)Did not meet inclusion criteria(n=43)Not palliative/hospice setting(n=18)Did not evaluate CAM in patients(n=15)Cohort
47、 study(n=3)Abstract(n=3)Quasi-experimental study(n=2)Case study(n=1)Secondary analysis(n=1)Study did not score 3 on Jadad scale(n=26)Studies included in qualitative synthesis(n=17)Fig.1.Flow diagram of steps in systematic review.Outlines steps taken and number of studies excluded and included in eac
48、hstep.784Vol.56 No.5 November 2018Zeng et al.Table 2Summary of Articles Included in Systematic ReviewPrimary Author(Year)Study DesignPatient PopulationaInterventionsDuration of StudyPrimarySymptom(s)AssessedPrimary OutcomeResultsAcupressurePerkins,P(2008)R,SB,C?Eight patients withterminal cancer?Med
49、ian age 61 yrs(range 48e74 yrs)?Acupressurewristbands(P6pressure point)(n 3)?Sham wristbands(n 5)Three days?Nausea?Vomiting?VAS?Total antiemetic doses?Antiemetic escalation?Change in emesisepisodes frombaseline?No evidence of differencebetween two groups for any endpoint?SSC:23,15,and 15 patientsnee
50、ded in each group to showdifference between change frombaseline emesis,antiemeticdoses,and VAS scoreAcupunctureLim,JTW(2011)R,NB,C?18 patients withincurable cancer?EG:mean age55?11.1 yrs(range31e72;eightwomen,two men)?CG:mean age64.9?8.7 yrs(range 53e81;seven women,oneman)?Acupuncture(n 10)?Nurse-le